from  whtoh  it  was  borrowed. 


WAR  SURGERY  OF   THE 
ABDOMEN 


WAR  SURGERY  OF 
THE  ABDOMEN 


BY 


G.M.G.,  F.R.C.S.  Eng.,  M.B.,  B.S.  Lond., 

>URI;KI>\,  >i.  THOMAS'  HOSPITAL;  LECTURER  ox  SI-RUKRY  IN  THK  MEDICAL 
SCHOOL;  CONSULTING  SURGEON.  BRITISH  ARMIES  IN  FRANCE 


WITH    26    ILLUSTRATIONS 


PHILADELPHIA 

P.   BLAKISTON'S  SON   &  CO. 

1012  WALNUT   STREET 

1918 


TO 
THE   STRETCHER-BEARER 


Printed  in  Great  Britain 


PREFACE 

THIS  Book  contains  the  experiences  in  abdominal  surgery  of 
a  sector  of  the  battle  line  over  a  period  of  thirty  months. 
It  is  founded  on  the  practice  of  many  surgeons,  working 
under  different  conditions  and  in  different  hospitals.  The 
personal  equation  and  influence  of  locality  have  thus  been 
largely  eliminated.  It  is  hoped,  therefore,  that  the  figures 
quoted  may  present  a  standard  with  which  other  surgeons 
can  compare  their  results. 

My  thanks  are  due  to  the  Medical  Research  Committee  for 
the  great  help  it  has  given.  It  has  provided  the  means  of 
recording  and  tracing  the  cases.  The  illustrations  are  the 
work  of  its  artist,  A.  K.  Maxwell,  to  whom  I  would  also 
express  my  indebtedness.  Many  of  the  blocks  have  been 
kindly  lent  by  the  Medical  Society  of  London  and  by  the 
Kritish  Journal  of  Surgery. 

CUTHBERT  WALLACE. 


CONTENTS 

CHAPTER   I. 

INTRODUCTORY. 

Foreword — Utility  of  Former  Experience — Exchange  of  Knowledge — 
Surgical  Opinion  when  the  War  started — Method  of  Treatment 
in  the  Earlier  Period  of  the  War — Experiences  of  the  Allies — 
Commencement  of  the  Operative  Treatment — Collection  and 
Evacuation  of  Wounded — Selection  of  Cases  for  Rapid  Evacuation 


CHAPTER   II. 

A  GENERAL  REVIEW  OF  ABDOMINAL  WOUNDS. 

Relative  Frequency  of  Abdominal  Wounds — Nature  of  the  Projectiles 
that  cause  the  Wounds— Relative  Number  of  Different  Projectiles 
and  the  Proportion  retained — Relative  Mortality  of  the  Different 
Projectiles — General  Incidence  of  Wounds — Influence  of  the 
Position  of  Wound  and  Direction  of  Missile  on  Prognosis — 
Possibility  of  Escape  of  Viscera  in  Penetrating  Wounds — The 
Possibility  of  Spontaneous  Recovery  after  the  Perforation  of 
Hollow  Viscera — Rupture  of  Viscera  outside  the  Actual  Course 
of  the  Projectile — Mechanism  of  Wound  Production  after 
Penetration — Comparative  Frequency  of  Wounds  in  the  Different 
Viscera — State  of  the  Alimentary  Canal  in  respect  of  its  Contents 
— State  of  the  Alimentary  Canal  in  respect  of  the  Nervo-muscular 
Mechanism  .  14 


CHAPTER    III. 

WHERE  TO  OPERATE. 

The  Time  Factor — Where  to  operate  on  Abdominal  Cases — Arrange- 
ments at  the  Present  Time  in  the  French  and  Belgian  Armies        .        45 


CHAPTER   IV. 

DIAGNOSIS  AND  TREATMENT  CONSIDERED  GENERALLY. 

Diagnosis  of  Intraperitoneal  Damage- — Care  of  the  Patient  before 
Operation — Question  of  Operation — Wounds  on  Back  to  be 
first  treated — -The  Incision — Treatment  of  the  Peritoneal  Cavity 
—Post -operative  Treatment  ......  51 


viii  CONTENTS 

CHAPTER   V. 
WOUNDS  OF  HOLLOW  ALIMENTARY  ORGANS  AND  THEIR  TREATMENT. 

PAGE 

Wounds  of  Particular  Organs — Stomach — Small  Intestine — Large 
Intestine — Character  of  the  Lesions  in  Different  Parts  of  the 
Colon — Rectum  (the  last  12  cm.  of  the  Alimentary  Canal) — 
Protrusion  of  Omentum  and  Viscera — Behaviour  of  the  Omen- 
turn  in  Abdominal  Wounds  .  .  65 


CHAPTER   VI. 

WOUNDS  OF  SOLID  ALIMENTARY  ORGANS  AND  SPLEEN. 
Liver — Pancreas — Spleen     ...  .100 

CHAPTER   VII. 

GENITO-URINARY  ORGANS. 
Kidney— Ureter— Bladder 109 

CHAPTER  VIII. 

ABDOMINO-THORACIC  WOUNDS  AND  DIAPHRAGMATIC  HERM  K. 
Abdomino-thoracic  Wounds — Diaphragmatic  Hernise       .          .          .119 

CHAPTER   IX. 

CAUSES  OF  FAILURE. 
Haemorrhage — Sepsis — Clinical  Shock  .          .          .          .          .          .129 

CHAPTER   X. 

STATISTICS,  RESULTS,  AND  THE  FUTURE. 

Mortality  in  the  Preoperative  Days — Methqd  of  recording  Cases — 
Comparative  Mortality  at  Different  Hospitals — Results  of 
Operative  Treatment— The  Future  .  .  .  .  .141 

INDEX  .     148 


WAR  SURGERY   OF  THE 
ABDOMEN. 

CHAPTER   I. 

INTRODUCTORY. 

Foreword. 

IT  may  be  asked  if  there  is  really  such  a  thing  as  war 
surgery  as  distinct  from  civil  surgery.  Fundamentally  there 
is  not  so  much  difference  as  might  be  thought.  What  difference 
there  is  lies  in  the  anatomical  nature  of  the  injuries,  such 
injuries  being  influenced  in  a  certain  proportion  of  the  cases 
by  the  high  speed  of  the  projectile  and  by  the  carrying  into  the 
wound  of  infective  material. 

It  is  a  question  as  to  whether  war  conditions  allow  the 
surgeon  to  apply  the  principles  that  he  knows  to  be  right. 
No  man  shot  in  the  belly  would  be  left  to  lie  in  bed  in  the  civil 
hospital  of  a  great  town.  The  expectant  treatment  was  only 
adopted  because  the  surgeon  could  not  operate  under  favourable 
conditions. 

War  surgery  is  largely  concerned  in  overcoming  adverse 
circumstances  and  in  striving  to  make  war  conditions  as  much 
like  peace  conditions  as  possible.  It  is  in  great  measure  a 
matter  of  when  and  where  to  operate  and  how  best  to  move  the 
wounded  man  to  the  place  where  he  will  win  back  to  health. 

At  first  the  circumstances  of  the  surgeon  are  strange.  He 
cannot  at  first  orient  himself  or  get  his  bearings.  Strange 
problems  present  themselves,  and  the  surgeon  feels  lost.  As  he 
grows  more  familiar  with  his  surroundings  he  recognises  that 
his  enemies  are  the  same,  but  under  a  new  guise.  Then  his 
way  becomes  clearer,  and  he  perceives  that  the  old  surgical 
truths  are  as  true  as  ever. 

W.S.A.  1 


2  War  Surgery  of  the  Abdomen 

Take  compound  fractures.  Early  on  in  the  war  these  were 
practically  untreated  as  regards  attention  to  the  interior  of  the 
wound  until  they  arrived  at  the  base  many  hours  after  their 
receipt.  They  did  badly,  and  what  surgeon  in  civil  practice 
would  be  surprised  if  fractures  left  uncleaned  for  sixteen  to 
twenty-four  hours  exhibited  violent  sepsis  ?  When  preparations 
were  made  at  the  Front  for  mechanical  cleaning  within  a  few 
hours  of  the  wound — when  the  civil  practice  gained  acceptance — 
there  was  at  once  a  vast  improvement.  It  took  nearly  three 
years  of  war  to  evolve  this  method,  and  yet  it  is  in  the  books 
written  years  ago. 

Again,  take  the  battle  of  antiseptics  as  applied  to  recent 
wounds.  It  was  a  failure  of  antiseptics,  and  not  of  asepsis, 
if  there  was  a  failure.  Surgeons,  horrified  at  the  bad  course 
of  the  wounds,  tried  antiseptic  after  antiseptic.  This  trial 
was  bred  of  despair,  and  as  in  the  past,  so  in  this  war,  we 
have  seen  the  surgeon  turn  from  one  chemical  to  another. 
It  was  not  until  the  well-established  surgical  practice  of 
excision  of  dead  and  dirty  tissue  was  again  adopted  within 
a  reasonable  time  of  wounding  that  any  material  progress 
was  made. 

All  surgery  must  be  governed  by  the  conditions  in  which  it 
is  practised  and  must,  therefore,  be  somewhat  modified  by  war, 
but  in  no  previous  war  has  the  medical  man  had  it  so  much  his 
own  way. 

Most  of  the  doctors  in  this  war  were  till  lately  civilians, 
and  possibly  inclined  to  be  impatient  of  routine.  Without 
administration  or  routine  the  finest  hospital  would  be  of  but 
little  value,  for  patients  would  arrive  late  and  in  bad  con- 
dition ;  on  the  other  hand,  administration  largely  exists  to 
allow  the  doctor  to  practise  his  art. 


Utility  of  Former  Experience. 

This  is  somewhat  doubtful.  In  some  ways  it  has  been  a 
hindrance.  In  judging  the  number  of  wounded,  the  proportion 
of  killed  to  wounded,  the  accommodation  required,  it  seems 
to  have  been  a  help,  for  such  things  alter  but  little,  though 


Introductory  3 

they  arc  altering.     As  a  general  guide  to  surgery  it  has,  if 
anything,  been  somewhat  of  a  handicap. 

In  South  Africa  one  learnt  to  treat  many  wounds  with  little 
respect.  Wounds  were  allowed  to  scab  over,  and  did  remarkably 
well.  Many  surgeons  became  convinced  that  rest,  starvation, 
and  morphia  were  the  right  treatment  of  abdominal  wounds. 
This  war,  fought  on  an  infected  soil,  has  proved  that  dirty 
wounds  must  be  cleaned.  It  has  also  shown  that  the  penetrating 
abdominal  wound  should  be  explored. 

Exchange  of  Knowledge. 

The  changing  conditions  of  wars  seem  to  show  that  surgical 
histories  brought  out  after  the  war  are  largely  a  labour  loss, 
if  not  a  waste  of  time.  A  series  of  well-observed  cases  and  the 
careful  drawing  of  deductions  while  the  war  is  in  progress  are 
worth  pages  of  statistics  when  the  fight  is  over.  Every  effort 
must  be  made  to  summarise  and  render  accessible  the  experiences 
of  the  early  months  for  use  in  the  later.  This  has  been  done 
by  both  combatant  and  medical  branches  by  means  of  pamphlets, 
instructions,  lectures,  and  demonstrations. 

The  Army  is  full  of  schools,  where  officers  and  men  are  taught 
new  methods.  A  short  course  at  a  school  is  more  valuable 
than  sheets  of  printing,  and  produces  greater  results. 

The  passing  of  a  wounded  man  from  one  unit  to  another  is 
unavoidable  in  war,  but  every  means  must  be  taken  to  lessen 
the  disadvantage.  This  is  best  done  by  sending  careful  notes 
with  the  patient  as  he  passes  from  the  Front  to  the  Base  and 
by  letting  the  surgeon,  who  first  had  charge  of  the  case,  know 
his  after-history.  The  front  line  surgeon  can  thus  collect  data 
and  modify  his  treatment  accordingly.  It  should  be  just  as 
incumbent  on  the  Base  to  supply  information  to  the  Front  as 
for  the  Front  to  supply  the  Base. 

Sympathy  between  units  is  very  necessary  for  the  smooth 
and  efficient  working  of  the  medical  service.  There  is  always 
a  tendency  to  criticise  the  unit  in  front  of  you  ;  but  it  is 
well,  if  you  feel  thus  inclined,  to  try  and  put  yourself  in  the 
place  of  the  man  from  whom  you  received  the  case.  An  exchange 

1—2 


4  War  Surgery  of  the  Abdomen 

of  information  leads  to  good  feeling.     A  friendly  criticism  is 
helpful,  a  captious  criticism  distinctly  harmful. 

Again,  one  of  the  most  useful  functions  of  a  consulting  surgeon 
has  been  the  carrying  of  facts  and  opinion  from  one  unit  to 
another.  The  so-called  radial  method  of  surgical  control  is  best, 
that  is,  where  the  surgeon  is  responsible  for  the  wounded  of  a 
certain  sector  of  the  line  both  at  the  Front  and  Base.  Unfor- 
tunately, this  cannot  be  always  managed,  and  in  heavy  fighting 
the  wounded  from  one  portion  of  the  line  will  flow  into  many 
base  areas.  In  quiet  times  it  is  possible  under  certain  condi- 
tions, and  much  knowledge  is  thus  gained  that  can  be  utilised  in 
fighting  times.  It  is  the  peace-time  observation  that  is  so 
useful,  as  then  there  is  time  for  deliberate  thought. 

Medical    societies    have    been    instituted    in    different  areas, 
and  have  done  good  work.    One  society  where  medical  officers 
both  from  the  Front  and  Base,  have  met,  has  been  of  the  greatest 
value.    Men  who  meet  and  discuss  matters  will  seldom  quarrel, 
especially  if  they  dine  together  afterwards. 

Surgical  Opinion  when  the  War  started. 

There  is  no  doubt  that  for  many  years  it  has  been  held  that  the 
operative  treatment  of  abdominal  wounds  was  not  to  be  advised 
under  war  conditions.  This  was  partly  due  to  want  of  success, 
and  partly  to  the  fact  that  many  military  surgeons  were  opposed 
to  extensive  operating  anywhere  near  the  firing  line.  As 
abdominal  surgery,  to  be  successful,  must  be  done  at  once,  it 
is  obvious  that  it  could  not  be  undertaken  with  success  where 
all  operations  had  to  be  postponed  to  a  late  period.  Although 
the  expectant  treatment  was  the  orthodox  one  when  the  South 
African  War  broke  out,  many  civil  surgeons  hoped  to  prove  that 
it  was  wrong.  Surgeon-General  W.  F.  Stevenson  even  issued 
an  appeal  for  the  trial  of  operation.  The  result  was,  however, 
only  to  confirm  former  opinion,  though  this  opinion  was  now 
held  on  two  somewhat  different  grounds.  One  school  held  that 
the  expectant  treatment  was  in  itself  the  right  procedure,  the 
other  that  it  was  the  best  that  could  be  done  in  war. 

Some  people  believed  that  wounded   intestine  healed  suffi- 


Introductory  5 

cicntly  often  to  warrant  abstention ;  others,  headed  by  Makins, 
believed  that  small-gut  lesions  were  practically  always  fatal, 
and  that  the  success  obtained  by  the  "  wait  and  see  "  policy  was 
due  to  the  escape  of  the  bowel,  although  the  belly  had  been 
penetrated.  Makins'  opinion  that  the  small  gut  area  could  be 
traversed  by  the  small  bullet  without  injury  has  been  proved 
in  this  war.  If  one  reads  the  literature  of  the  South  African 
War,  both  private  and  official,  the  reason  for  want  of  success 
is  at  once  obvious — the  cases  arrived  too  late.  It  was  not  so 
much  a  question  of  the  success  of  the  expectant  treatment  as  a 
failure  of  the  operative.  Operations  were  secondary  or  late, 
and  two  strikingly  successful  cases  of  resection  of  small  gut 
(Messrs.  Neale  and  Tuke)  were  operated  on  within  six  and 
twelve  hours  respectively. 

The  reason  for  the  late  operation  was  the  nature  of  fighting  in 
an  unsettled  country  of  great  distances.  The  wounded  could 
not  be  quickly  brought  to  a  hospital  equipped  with  the  necessary 
appliances.  To  operate  in  the  veldt  with  what  appliances  were 
at  hand  was  too  disheartening.  It  was  impossible  to  get  even 
moderately  decent  conditions.  There  was  little  or  no  water, 
and  what  there  was  was  often  too  filthy  for  words — the  water 
of  dams.  In  addition  there  was  the  plague  of  flies  and  dust 
that  settled  on  everything.  Lastly,  the  operated  man  could  not 
be  kept  quiet ;  it  was  lucky  if  he  could  ride  in  a  horse 
ambulance. 

The  conditions  were  utterly  different  from  what  now  pertain, 
and  this  is  the  first  time  since  the  rise  of  abdominal  surgery  that 
a  great  campaign  has  been  fought  in  a  settled  country,  and, 
what  is  more  important  still,  with  a  fixed  fighting  line. 

The  small  number  of  figures  dealt  with  in  the  South  African 
campaign  was  also  a  source  of  error.  In  order  to  form  an 
adequate  idea  of  the  efficacy  of  any  treatment  it  is  necessary 
to  strike  an  average  over  a  large  series  of  cases.  Now,  in  this 
present  war,  one  of  the  difficulties  of  establishing  the  operative 
treatment  was  the  runs  of  bad  luck  which  any  operator  had  to 
face.  Even  now,  with  conditions  as  near  ideal  as  possible,  one 
may  meet  a  series  of  nine  consecutive  fatal  cases.  This  must 
have  a  very  depressing  effect  on  any  young  surgeon,  or  one  who 


is  not  convinced  that  the  operative  treatment  is,  in  the  main, 
the  best  of  all.  Now,  nine  abdominal  cases  mean,  roughly, 
about  600  wounded  men,  taking  a  moderate  estimate  of  the 
proportion  of  abdominal  wounds  to  total  wounds.  As  a  matter 
of  fact,  in  the  South  African  campaign,  a  casualty  list  of  600 
wounded  was  considered  a  large  one.  It  can  therefore  be  seen 
that  if  an  operator  happened  to  encounter  such  a  series  it  is 
not  a  matter  for  surprise  if  he  had  doubts  as  to  the  correctness 
of  his  procedure. 

The  statistics  of  the  South  African  campaign  are  very  defec- 
tive. Surgeon-General  Stevenson,  in  the  official  history  of  the 
war,  was  only  able  to  collect  207  cases  of  abdominal  wounds. 
Among  them  it  is  stated  that  there  were  26  laparotomies  with 
18  deaths,  a  mortality  of  69 '2  per  cent.,  and  according  to 
Stevenson  the  mortality  was  really  even  worse.  The  total 
death-rate  of  all  abdominal  wounds  quoted,  operated  and 
unoperated,  is  given  as  30-4  per  cent. 

In  his  most  recent  work  (1910),  "  Wounds  in  War,"  the 
mortality  is  shown  as  51-6  for  laparotomies,  the  total  cases 
remaining  the  same — namely,  207.  In  any  case  the  numbers 
are  really  too  small  to  have  any  real  value. 

Figures  show  that  in  the  present  campaign  a  mortality 
of  50  per  cent,  is  a  good  result,  but  such  a  mortality  in 
civil  practice  would  be  considered  an  awful  death-rate  to  face. 
And  yet  it  means,  looking  on  the  bright  side,  many  lives 
saved. 

There  is  no  doubt  that  certain  people  shot  through  the 
abdomen  in  South  Africa,  and  treated  expectantly,  recovered. 
As  a  matter  of  fact,  there  were  two  officers  well  known  in  the 
Royal  Army  Medical  Corps  who  recovered  after  such  treatment, 
and  I  have  no  doubt  that  a  knowledge  of  their  recovery 
greatly  strengthened  the  opinion  that  expectant  treatment 
was,  on  the  whole,  the  best. 

The  South  African  campaign  may  then  be  said  to  have  left 
surgical  opinion  opposed  to  operation.  This  opinion  seems  to 
have  been  only  strengthened  by  succeeding  wars — the  French 
War  in  Morocco,  the  Balkan  War,  and  the  Russo-Japanese 
War. 


Introductory  7 

Method  of  Treatment  in  the  Earlier  Period  of  the  War. 

It  is  not  intended  here  to  say  anything  about  the  period  of 
the  retreat.  Under  such  conditions  adequate  provision  for 
operating  near  the  Front  was  an  impossibility,  and  all  that  could 
be  done  was  to  get  rid  of  the  wounded  to  the  Base  with  the 
least  possible  discomfort  to  them.  When  the  line  became  fixed 
the  conditions  were  very  different,  and  there  was.  a  possibility 
of  operating  under  good  conditions.  It  was  no  longer  a  question 
of  whether  a  man  could  be  operated  upon,  but  whether  he  should 
be  operated  upon.  Still,  however,  the  old  belief  in  the  efficacy 
of  the  expectant  treatment  obtained. 

In  order  to  understand  what  was  done  during  this  period  it  is 
necessary  to  say  a  word  or  two  about  the  standard  system  by 
which  the  wounded  man  was  evacuated.  Shortly,  it  was  as 
follows  :  A  wounded  man  was  first  seen  by  the  regimental 
medical  officer,  to  whom  he  was  brought  in  the  regimental  aid- 
post  situated  somewhere  in  the  trench  system.  He  was  then 
transferred  by  a  stretcher  to  an  advanced  dressing  station, 
usually  situated  just  behind  the  trenches,  and  from  there  by  car 
to  the  Field  Ambulance,  and  there  he  was  kept  until  the  time 
the  motor  convoy  arrived,  often  only  once  in  the  twenty-four 
hours.  By  this  he  was  taken  to  the  Casualty  Clearing  Station, 
which  was  the  first  place  adequately  equipped  for  operative  treat- 
ment. In  the  early  days  the  Clearing  Station  was  a  very  different 
hospital  from  what  it  is  now,  but  still  there  was  reasonable 
facility  for  the  performance  of  any  operation  if  it  was  thought 
advisable.  With  the  idea  of  avoiding  the  disturbance  of  move- 
ment, a  man  wounded  in  the  abdomen  was  kept  sometimes, 
though  not  usually,  in  the  regimental  aid-post ;  often  he  was 
kept  at  a  Field  Ambulance,  but  usually  he  was  transferred  to 
the  Casualty  Clearing  Station  and  there  treated. 

The  usual  mode  of  procedure  was  to  put  the  man  in  the 
Fowler  position,  to  improve  the  general  condition  by  rest  and 
warmth,  to  withhold  food  and  water  for  three  days,  and  to 
administer  morphia.  The  thirst,  which  was  a  distressing 
symptom  of  this  treatment,  was  combated  to  a  certain  degree 
by  rectal  salines  and  mouth-washes. 


8  War  Surgery  of  the  Abdomen 

I  should  like  here  to  pay  tribute  to  the  great  care  and  atten- 
tion which  the  medical  officers  lavished  on  the  cases.  Certain 
officers  were  told  off  day  and  night  to  attend  to  these  patients, 
and  everything  that  could  be  done  to  alleviate  their  suffering 
and  to  make  them  as  comfortable  as  possible  and  to  cheer  them 
up  was  done.  If  anything  could  have  got  these  men  well  the 
attention  that  they  received  would  have  done  so.  The  people 
who  conducted  the  treatment  were  firmly  convinced  of  its 
efficacy. 

This  belief  was  strengthened  by  the  behaviour  of  the  patient. 
Many  patients,  at  first  gravely  ill,  went  through  a  period  of 
improvement  which  often  was  very  striking.  It  was  in  a  way 
unfortunate,  but  there  is  no  doubt  that  improvement  did  take 
place,  and  so  well  were  many  of  them  that  they  were  evacuated 
to  the  Base,  and  arrived  there  sometimes  in  good  condition 
and  sometimes  gravely  ill.  The  men  who  saw  the  cases  leave 
them  apparently  on  the  way  to  recovery  could  not  bring  them- 
selves to  believe  that  such  cases  did  badly  at  the  Base.  It  was 
unfortunate  that  the  means  of  communication  between  the 
Base  and  the  Front  was,  in  those  days,  inadequate,  and  this 
serves  to  emphasise  what  has  already  been  stated  about  the 
value  of  free  interchange  of  reports  between  the  Front  and 
the  Base. 

If  .evacuation  of  these  cases  had  not  been  necessary  and  it 
had  been  possible  to  keep  them  at  the  Clearing  Stations,  the 
expectant  treatment  would  not  have  survived  as  long  as  it 
did,  for  medical  officers  would  have  seen  such  cases  become 
worse  and  worse,  and  in  the  end  die.  As  a  matter  of  fact,  during 
my  six  months'  experience  at  the  Red  Cross  Hospital  at  Netley 
I  only  saw  two  cases  of  wounds  of  the  abdominal  viscera  ;  one 
was  a  case  of  caecostomy  and  the  other  a  transverse  colostomy. 

The  expectant  treatment  was  also  a  very  trying  time  for  the 
wounded  man.  The  knowledge  that  nothing  could  be  done  for 
him  by  operation,  and  that  the  only  thing  was  to  wait  events, 
had  a  very  depressing  effect  on  the  soldiers,  although  the  medical 
officers  did  everything  to  cheer  them  up. 

It  is  curious,  but  true,  that  the  wounded  soldier  welcomes 
operation.  He  feels  that  something  is  being  done  for  him.  I 


Introductory  9 

have  sometimes  been  asked  the  question,  "  Can't  you  operate  ?  " 
If  I  have  answered  in  the  negative,  with  an  assurance  that 
operation  was  unnecessary  and  that  he  would  do  well,  I  have 
often  detected  a  look  of  disappointment  on  the  patient's  face. 
Operation  has  no  horror  for  the  soldier. 

Experiences  of  the  Allies. 

The  French  have  gone  through  the  same  experience  in  the 
treatment  of  abdominal  wounds. 

I  cannot  do  better  than  quote  you  a  letter  which  Professor 
Turner  has  kindly  written  me.  He  says  :— 

"  Abdominal  surgery  has  undergone  in  France  the  following 
revolution.  Until  the  month  of  February,  1915,  installations 
did  not  allow  one  to  operate,  under  good  conditions,  on  wounds 
of  the  abdominal  cavity,  and  abstention  was  necessary  in  these 
circumstances.  At  this  period  I  found  in  a  small  ambulance 
quite  near  the  Front,  and  very  well  organised,  several  cases  of 
cure  of  wounds  of  the  intestine  by  laparotomy.  I  reported  them 
to  the  Society  of  Surgery,  and  a  movement  commenced  in 
favour  of  operation  for  all  abdominal  wounds.  It  is  because  the 
motor  surgical  ambulances  and  the  medical  arrangements  have 
been  better  organised,  and  because  the  evacuation  of  the 
wounded  has  been  done  in  a  relatively  short  time,  that  we  have 
been  able  to  arrive  at  a  certain  measure  of  success." 

With  the  French,  as  with  us,  the  period  of  the  retreat  corre- 
sponded to  the  period  of  expectant  treatment,  and  when  the 
line  became  fixed  the  treatment  underwent  the  same  change 
as  it  did  in  the  British  Army.  As  a  matter  of  fact,  after  the 
establishment  of  the  operative  treatment  some  French  surgeons 
have  from  time  to  time  again  championed  the  expectant  treat- 
ment, but  this  finds  little  acceptance  with  the  majority. 

Commencement  of  the  Operative  Treatment. 

Although  rest  treatment  was  the  rule  in  the  first  days  of 
the  war,  some  attempts  at  operation  were  made.  Souttar  also 
commenced  early  operation  with  the  Belgian  Army.  Owen 
Richards  was  the  first,  I  believe,  to  publish  results  of  operative 


io  \Var  Surgery  of  the  Abdomen 

treatment  in  the  British  Army.*  His  first  operation  was  per- 
formed on  January  28th,  1915,  and  the  first .  successful  case, 
that  of  a  resection  of  2i  feet  of  the  small  intestine,  was 
operated  upon  on  March  18th,  1915,  thirty-six  hours  after  receipt 
of  the  injury.  A  few  other  British  surgeons  had  tried  what 
could  be  done  by  operation,  but  the  results  were  undeniably 
bad,  so  bad  that  most  people  had  abandoned  the  attempt. 
The  reason  for  this  was,  no  doubt,  the  late  arrival  of  the  cases 
at  a  place  where  an  operation  could  be  performed. 

In  June,  1915,  a  series  of  operations  and  post-mortem  examina- 
tions showed  that  the  injuries  were  of  such  a  nature  that 
recovery  was  not  to  be  expected  without  surgical  aid  except  in 
a  few  instances. 

It  was  also  found  that  haemorrhage  was  a  frequent  cause  of 
early  death,  and  that  bullets  produced  very  extensive  injuries. 
It  has  always  been  granted  that  haemorrhage  was  the  chief  cause 
of  early  death,  but  the  advocates  of  expectant  treatment  seem 
to  have  focussed  their  attention  more  on  the  danger  of  peri- 
toneal infection  and  the  possibility  of  its  localisation  or  dis- 
appearance than  on  the  possibility  of  spontaneous  arrest  of 
haemorrhage. 

The  discovery  that  bullets  produced  extensive  gut  injuries 
was  also  of  great  importance,  as  much  stress  had  been  laid  on 
the  smallness  of  the  lesions  produced  by  the  modern  small-bore 
bullet ;  in  fact,  the  hope  of  spontaneous  recovery  from  gut 
lesions  was  based  on  the  assumption  that  such  projectiles  were 
comparatively  innocuous.  This  idea  was  constantly  put  forward 
in  the  early  period  of  the  war. 

The  re-establishment  of  the  fact  that  haemorrhage  was  the  chief 
cause  of  early  death  was  of  great  importance,  as  it  showed  that 
only  by  rapid  evacuation  could  one  hope  to  combat  such  a  con- 
dition. In  June,  1915,  Surgeon-General  W.  G.  Macpherson 
directed  some  of  the  Field  Ambulances  to  send  the  abdominal 
wounds  with  all  possible  celerity  to  the  nearest  Casualty  Clearing 
Station.  The  results  obtained  by  this  small  experiment  were 
encouraging,  and  in  the  first  week  in  August,  1915,  an  order 
was  given  which  made  the  rapid  evacuation  of  abdominal 

*  Brit.  Med.  Journ.,  August  7th,  1915. 


Introductory  11 

wounds  the  official  method.    This  was  followed  by  rapid  improve- 
ment in  the  results  obtained. 


Collection  and  Evacuation  of  Wounded. 

In  forming  a  judgment  on  the  results  obtained  by  the  opera- 
tive treatment  of  abdominal  injuries  and  where  it  is  best  to 
operate  on  them  it  is  necessary  to  know  something  about  the 
means  by  which  such  cases  reach  a  Casualty  Clearing  Station. 
A  knowledge  of  the  difficulties  is  also  necessary  in  order  to  form 
an  appreciation  of  the  really  magnificent  work  which  is  being 
done  by  the  regimental  medical  officer  and  his  stretcher-bearers, 
and  by  the  personnel  of  the  Field  Ambulances.  One  can 
consider  this  subject  under  two  heads  :  (1)  the  collection  ;  (2)  the 
evacuation  of  the  wounded  man. 

(1)  By  collection  is  meant  the  finding  and  bringing  back  to  the 
Regimental  Aid-Post  of  the  wounded  ;    and  without  going  into 
particulars  it  can  be  well  understood  what  the  difficulties  are 
when  an  attack  has  been  made  and  our  troops  have  advanced. 
If  it  is  difficult  to  find  and  collect  the  wounded  after  a  successful 
attack,  it  is  still  more  difficult  when  the  fortunes  of  battle  sway 
backwards  and  forwards  ;    and  it  is  under  the  latter  conditions 
that  the  wounded  lie  out  for  a  considerable  period.     In  quiet 
times  the  collection  is  not  difficult,  for  the  men  are  wounded 
very  often  in  the  trenches  themselves. 

(2)  The  Evacuation. — A  man  has  been  wounded  in  the  front 
trench.     The  first  field  dressing  most  probably  will  be  applied 
by  himself  or  by  one  of  his  companions,  possibly  by  the  medical 
officer  himself.     The  patient  will  then  walk,  be  carried,  or  be 
taken  on  some  kind  of  stretcher  to  the  Regimental  Aid- Post. 
Even  this  is  performed  under  considerable  difficulties,  because 
the  nature  of  the  trench  system  involves  getting  round  many 
sharp  angles.    The  Regimental  Aid-Post  is  situated  somewhere  in 
the  trench  system  or  in  a  communication  trench.    To  reach  this, 
even  in  quiet  times,  an  hour  or  more  may  sometimes  be  required. 
It  is  in  a  dug-out,  a- cellar,  or  a  ground  floor   room  reinforced 
and  sandbagged.     There  is  a  dressing-room,  fitted  up  as  well  as 
possible  with  shelves  and  trestles.    Adjoining  will  be  some  place 


12  \Yar  Surgery  of  the  Abdomen 

where  the  wounded  may  rest  till  evacuated.  There  may  be 
electric  light,  though  usually  there  is  only  an  acetylene  lamp  or 
a  humble  candle.  It  is  not  a  place  where  any  one  would  wish 
to  perform  a  capital  operation.  Here  the  patient  will  be 
attended  by  the  regimental  medical  officer.  He  will  be  properly 
dressed,  fed,  given  hot  drinks,  warmed  up,  adequately  covered 
with  blankets,  and  provided  with  hot  bottles. 

Under  the  present  system  of  evacuation  an  abdominally 
wounded  man  will  not  wait  in  this  place.  Now  commences  the 
long  journey — sometimes  as  much  as  two  miles — down  the 
communication  trench.  Sometimes  the  journey  is  so  arduous 
that  one  complete  tour  is  all  that  a  stretcher  party  can  manage 
without  a  long  spell  of  rest.  Underfoot  are  the  duck  boards  or 
a  rough  brick  pavement.  The  provision  of  these  renders  walking 
more  easy,  but  the  surface  is  necessarily  uneven,  especially 
where  one  board  joins  another.  Sometimes  a  rung  is  out,  and  at 
other  times  the  board  is  apt  to  tilt  and  look  you  in  the  face. 
Then  there  are  the  innumerable  corners  formed  by  the  zigzags 
of  the  trench  made  to  stop  the  enfilade  fire  and  limit  the  danger 
of  an  exploding  shell,  or  to  prevent  the  enemy  looking  straight 
down  the  trench. 

In  summer  the  air  is  stifling.  In  winter,  or  after  rain,  the 
surface  of  the  boards  is  greasy  in  the  extreme,  and  sometimes 
they  are  completely  under  water.  At  night-time  the  difficulties, 
as  may  be  well  imagined,  are  greatly  increased.  Sometimes  the 
turns  in  the  trenches  are  so  sharp  that  the  traverses  of  the 
stretcher  have  to  be  closed  in  order  to  allow  its  passage  round 
the  corners,  or  it  has  to  be  lifted  high  above  the  angle. 

Much  ingenuity  has  been  expended  in  devising  stretchers 
for  the  easier  transit  of  the  wounded  man,  for  getting  round 
corners  easily,  and  relieving  the  work  of  the  bearers.  In  most 
cases  the  stretchers  are  carried  on  the  bearers'  shoulders  ;  the 
regulation  method  has  been  found  much  too  fatiguing. 

Many  wheeled  stretchers  have  been  tried,  but  the  inequalities 
of  the  ground  and  the  sharp  corners  to  be  turned  are  difficulties 
which  have  not  yet  been  overcome.  Sometimes  it  is  possible 
to  put  a  man  on  a  trolley-line  or  light  railway  and  run  him 
down  over  the  open  ground.  In  some  cases  the  trenches  have 


Introductory  13 

an  overhead  mono-rail  on  which  a  short  form  of  stretcher  can 
be  suspended. 

At  the  end  of  the  communication  trench  the  patient  comes  to 
the  Advanced  Dressing  Station.  This,  as  a  rule,  is  more  spacious 
than  the  Regimental  Aid-Post,  but  similar  in  construction. 
Here  the  patient  is  again  warmed  up  and  given  drink.  The 
hot  bottles  are  changed  or  refilled  and  the  patient  despatched, 
if  his  condition  warrants  it,  in  a  motor  ambulance  to  the  Casualty 
Clearing  Station  or  Advanced  Operating  Centre.  Sometimes 
the  ambulance  will  call  at  the  Field  Ambulance  if  this  is  not  off 
the  route. 

The  above  description  applies  to  comparatively  quiet  times. 
In  times  of  battle  there  may  be  no  dug-outs,  cellars,  or 
overhead  shelters.  The  wounded  man  must  be  attended  to 
in  the  open,  in  the  lee  of  a  wall  or  "  pill-box,"  and  then  to  reach 
the  Advanced  Dressing  Station  he  must  be  carried  3,000 — 
5,000  yards  across  the  open,  the  bearers  on  whose  shoulders  the 
stretcher  rests  picking  a  precarious  way  along  the  edge  of 

innumerable  shell-holes  filled  with  mud  and  water. 

* 

Selection  of  Cases  for  Rapid  Evacuation. 

The  rapid  evacuation  of  all  abdominal  cases  to  the  Casualty 
Clearing  Stations  puts  a  great  deal  of  responsibility  on  the 
Field  Ambulance  officers.  It  is  no  light  task  to  decide  what 
cases  can  stand  evacuation  ;  in  fact,  it  is  one  of  the  most  difficult 
things  that  a  medical  officer  is  called  upon  to  determine.  .  Many 
patients,  of  course,  are  better  for  rest  and  food  and  warmth ;  but 
in  the  case  of  abdominal  wounds  it  must  be  remembered  that 
haemorrhage  is  the  chief  cause  of  early  death,  and  that  the  only 
hope  for  their  salvation  lies  in  the  arrest  of  the  haemorrhage  by 
surgical  means.  It  is  therefore  obvious  that  it  is  worth  while 
taking  risks  in  cases  of  abdominal  wounds  which  it  would  not 
be  right  to  take  in  other  cases.  There  is  also  the  danger  of 
death  from  peritoneal  infection,  but  experience  has  shown  that 
the  need  for  celerity  on  this  account  is  as  nothing  compared  to 
that  necessary  on  account  of  haemorrhage. 


CHAPTER   II. 
A  GENERAL  REVIEW   OF  ABDOMINAL  WOUNDS. 

Relative  Frequency  of  Abdominal  Wounds. 

IN  the  earlier  period  of  the  war  there  was  some  difficulty  in 
arriving  at  an  accurate  figure.  There  was  the  difficulty  of 
diagnosis  in  the  first  place.  In  the  second  place,  it  was  found 
that  the  data  varied  according  to  the  persuasion  of  the  surgeon 
who  made  the  observations.  A  medical  officer  who  believed 
in  the  expectant  treatment  gave  a  higher  proportion  than  one 
who  favoured  operation.  Again,  the  Field  Ambulances  always 
gave  a  higher  number  than  the  Casualty  Clearing  Stations. 

The  difference  between  the  figures  in  the  Field  Ambulances 
and  Casualty  Clearing  Stations  is  accounted  for  in  the  following 
manner  :  (1)  the  Field  Ambulance  would  naturally  and  rightly 
err  on  the  side  of  making  the  graver  diagnosis  ;  (2)  the  mortality 
was  high  in  the  Field  Ambulances,  so  that  fewer  cases  reached 
the  Casualty  Clearing  Station  ;  (3)  at  the  Casualty  Clearing 
Station  a  more  careful  diagnosis  acted  in  two  ways  :  (a)  it 
included  some  buttock,  chest,  back,  and  thigh  wounds  as 
abdominal  wounds  ;  (b)  it  excluded  many  cases  of  wounds  of 
parietes.  On  the  whole  the  effect  was  to  lessen  the  proportion 
of  abdominal  wounds  to  total  wounds. 

With  the  establishment  of  the  operative  treatment  and  the 
keeping  of  accurate  records  the  errors  have  diminished.  It  is 
now  possible  to  state  that  the  number  of  abdominal  wounds 
that  reach  an  operating  hospital  is  not  likely  to  exceed  2  per 
cent,  of  the  total  wounded  received,  provided  that  no  segrega- 
tion of  such  cases  is  practised. 

Nature  of  the  Projectiles  that  cause  the  Wounds. 

Bullets. — There  are  very  many  different  kinds  of  bullets  used 
in  this  war,  and  apparently  their  number  goes  on  increasing. 


A  General   Review  of  Abdominal  Wounds     15 

As  is  well  known,  the  standard  English,  French,  and  German 
bullet  is  a  pointed  one.  The  English  and  German  is  a  composite 
projectile  which  is  liable  to  break  up  into  mantle  and  core. 
The  French  bullet  is  much  longer  than  either  of  the  above, 
and  is  made  of  solid  copper  alloy.  Although  not  liable  to 
break  up,  it  is  liable  to  very  great  distortion.  Naturally  we  are 
mostly  concerned  with  the  German  projectile,  which,  as  a  rule, 
is  pointed,  but  sometimes  the  old  ogival-headed  bullet  has  been 
extracted  from  wounds.  All  the  modern  pointed  bullets  are 
more  unstable  than  the  bullets  of  the  Boer  War.  The  instability 
is  said  to  be  most  marked  at  the  beginning  and  the  end  of  the 
flight.  In  this  war,  where  the  fight  takes  place  amongst  houses, 
there  are  many  opportunities  for  the  bullet  to  be  deformed 
and  deflected.  Again,  the  velocity  and  stability  of  a  bullet  is 
largely  affected  by  passing  through  sandbags  or  a  parapet, 
which,  as  a  matter  of  fact,  has  to  be  something  like  4  feet  thick 
to  be  bullet-proof.  There  is  plenty  of  evidence  that,  whether 
from  inherent  instability  or  from  hitting  some  object,  the 
bullet  does  spin,  and  in  several  cases  a  bruised  impress  has  been 
seen  on  the  skin  which  could  only  have  been  made  by  a  sidelong 
impact  of  the  bullet.  Again,  in  those  cases  where  two  legs 
have  been  wounded  by  the  same  bullet  the  first  leg  has  been 
perforated  by  a  small  standard  track,  and  the  opposite  leg  has 
suffered  a  large  gaping  wound,  the  obvious  explanation  being 
that  the  bullet  in  passing  through  the  first  limb  was  made  to 
spin,  and  so  caused  a  more  extensive  wound  on  the  opposite 
member.  A  good  deal  has  been  heard  about  the  explosive  effect 
of  the  modern  pointed  bullet  ;  and  although  one  may  say  that 
it  does  cause  worse  wounds  than  the  ogival-headed  projectile, 
I  am  by  no  means  persuaded  that  its  so-called  explosive  effect 
is  anything  but  a  very  rare  occurrence.  I  am  strengthened  in 
this  opinion  by  the  study  of  accidental  wounds,  of  which  one 
sees  a  great  number.  Men  are  shot  at  all  sorts  of  close  ranges 
up  to  actual  contact,  and  yet,  unless  a  hard  bone  is  touched,  it 
is  not  usual  to  get  the  explosive  type  of  wound. 

Shell  Fragments. — These  are,  of  course,  of  all  sizes,  but  the 
fragments  which  are  the  cause  of  the  abdominal  wounds  that  the 
surgeon  is  called  to  treat  are  generally  not  more  than  1|  inch 


7 


9 


10 


11. 


FIG.  1. — Types  of  Projectiles  that  cause  Abdominal  Wounds. 

(1)  Piece  of  H.E.  shell.  Wounded  small  gut  and  lodged  in  mesentery.  (2)  Rifle  grenade 
fragment.  Penetrated  through  the  gantro-hepatic  omentum  and  divided  all  the 
tissues  of  the  left  kidney.  (3)  German  bullet.  (4)  British  bullet.  (5)  Shoe  nails 
from  an  early  German  bomb.  (6)  Fragment  of  grenade.  Wounded  small  gut. 
(7)  Lead  fragment.  Penetrated  the  back  and  wounded  jejunum.  (8)  Fragment  of 
H.E.  shell.  Penetrated  buttock  and  wounded  bladder.  (9)  Frajfment  of  bomb. 
Penetrated  the  back  and  wounded  jejunum.  (10)  Bomb  fragment.  Penetrated 
under  ribs  and  wounded  kidney.  (11)  Shell  fragment.  Wounded  jejunum  in  three 
places.  (12)  Fragment  of  H.E.  shell.  Penetrated  belly  wall,  carried  in  portions  of 
clothes,  but  wounded  no  viscus.  (13)  Fragment  «.f  H.E.  chell.  Wounded  liver. 
small  gut,  and  pelvic  colon.  Drawn  natural  size.  (Medicul  Society  and  lirit.  Journ. 
of  Surgery.) 


A  General   Review  of  Abdominal  Wounds     17 

in  the  greatest  diameter,  usually  a  good  deal  smaller.  There 
are  different  kinds  of  shells  used,  and  some  importance  may 
be  attached  to  the  nature  of  the  shell  by  which  the  man  is 
wounded. 

High-Explosive  Shells. — These  shells  may  burst  in  the  air,  on 
contact  with  the  ground,  or  after  they  have  impacted  themselves 
deeply  in  the  earth.  The  velocity  of  the  fragments  into  which 
the  shell  is  blown  depends  both  on  the  "  remaining  velocity  "  and 
on  the  disruptive  charge,  and  the  fragments  fly  out  mostly  in  a 
forward  and  lateral  direction.  The  shape  of  the  fragments 
depends  largely  on  the  type  of  shell — if  the  shell  is  segmented, 
the  pieces  are  more  or  less  quadrilateral ;  if  not  segmented, 
the  fragments  are  still  more  or  less  quadrilateral  in  shape,  and 
have  extremely  sharp  and  ragged  edges.  Such  shells,  bursting 
on  the  ground,  naturally  become  Covered  with  dirt. 

The  knowledge  of  where  a  shell  bursts  in  relation  to  the 
patient  is  sometimes  of  importance  as  telling  whether  the 
abdomen  is  involved.  If  a  shell  bursts  above  a  man  who  is 
wounded  in  the  lower  thorax  it  is  likely  that  the  fragment  has 
entered  the  peritoneum.  Again,  if  a  man  is  hit  in  the  buttock 
and  the  shell  explodes  on  the  ground  the  possibility  of  the 
pelvis  being  involved  should  at  once  be  borne  in  mind.  An 
officer  was  riding  along  a  road,  and  a  shell  burst  on  percussion 
quite  close  to  him.  He  had  a  buttock  wound.  A  fragment 
was  found  to  have  entered  the  pelvis  and  torn  the  small  gut 
and  a  large  pelvic  vein. 

Shrapnel. — These  shells  usually  burst  in  the  air  with  a  time 
fuse.  They  are  of  all  sizes,  and  the  metal  balls  with  which  they 
are  filled  also  vary  somewhat  in  size.  The  penetrating  power 
of  such  balls  is  due  to  the  remaining  velocity  of  the  shell.  The 
direction  of  the  shrapnel  balls  will,  as  a  rule,  be  downwards. 
In  some  cases  a  shell  is  of  a  combined  high-explosive  and 
shrapnel  type. 

Shell  Caps. — These  come  from  both  types  of  shell  and  form 
some  of  the  largest  fragments  that  the  surgeon  meets  with. 
They  often  cause  contusions  without  perforation. 

Bombs  and  Grenades. — In  the  early  part  of  the  war  these 
bombs  were  often  extemporised,  and  consisted  of  tin  boxes 

W.S.A.  2 


1 8  War  Surgery  of  the  Abdomen 

filled  with  an  explosive,  scrap  iron,  cobblers'  nails,  and  screws, 
etc.  Nowadays  they  are  made  of  iron,  the  surface  of  which  is 
marked  with  grooves,  so  that  on  explosion  they  break  up  into 
quadrilateral  fragments.  Sometimes  the  force  of  the  explosive 
will  cause  a  bomb  to  burst  into  smaller  fragments,  often  no 
bigger  than  a  big  match-head.  Although  small,  these  fragments 
have — apparently  from  their  high  velocity — a  very  great 
penetrating  power  in  the  immediate  neighbourhood  of  the 
explosion,  though  this  is  rapidly  lost  as  the  distance  increases. 

Trench  Mortars. — Bombs  from  these  are  of  various  shapes,  but 
consist  essentially  of  a  very  large  high-explosive  charge  with  a 
comparatively  thin  containing  envelope  ;  they  therefore  very 
often  burst  into  large  ragged  fragments  as  well  as  minute  ones. 
They  are  generally  timed  to  burst  either  on  the  ground  or  in  the 
ground. 

Bayonet  Wounds. — These  are  very  seldom  met  with,  being 
usually  fatal  on  the  field.  Mention  may  be  made  of  two  cases. 
In  the  first  the  bayonet  penetrated  the  man's  back  and  came 
out  by  his  umbilicus  ;  no  viscus  was  injured,  and  the  man 
succumbed  to  haemorrhage.  The  second  was  the  case  of  a  man 
who  was  late  in  answering  a  challenge,  and  was  bayoneted  by 
the  sentry ;  the  bayonet  entered  the  left  hypochondrium, 
wounded  the  greater  curvature  of  the  stomach,  and  entered  the 
back  wall  of  the  abdomen  ;  though  promptly  operated  on,  he 
died,  not  of  his  stomach  wound,  but  of  retroperitoneal  sepsis. 

Relative  Number  of  Different  Projectiles  and  the  Proportion  retained. 

Table  I.  has  been  drawn  up  with  the  intention  of  giving 
some  idea  of  the  relative  frequency  of  the  different  projectiles 
met  with  in  abdominal  wounds  ;  it  also  shows  the  number 
retained  in  the  body.  This  table  must  be  taken  as  only  approxi- 
mately correct,  for  several  reasons.  In  the  first  place,  it  is  often 
impossible  for  a  man  to  tell  what  hit  him  ;  in  the  second  place, 
one  cannot  always  be  sure,  from'  a  study  of  the  entrance  and 
exit  wounds,  what  was  the  nature  of  the  projectile  ;  and,  again, 
many  do  not  differentiate  between  high-explosive  shell  and 
shrapnel,  the  soldier  generally  including  most  shells  which  are 


A  General   Review  of  Abdominal  Wounds     19 


not  of  a  large  calibre  under  the  name  of  shrapnel.  As  a  matter 
of  fact,  there  is  very  little  difference  in  the  nature  of  the  frag- 
ments in  high-explosive  shells,  bombs,  rifle  grenades,  or  trench 
mortars,  if  one  excludes  the  larger  fragments,  with  which  we 
are  very  little  concerned. 

TABLE  I. — Relative  Frequency  of  Different  Projectiles  met  with 
and  of  those  retained.    Total  Number  of  Cases,  834. 


— 

Bullet. 

Shell 
Fragment. 

Shrapnel. 

Bomb  or 
Grenade. 

Out 
Retained 

203 
131 

30 
254 

15 

67 

6 
128 

Total 

334 

284 

82 

134 

Bullets. — Bullets  and  high-explosive  shell  furnish  the  larger 
proportion  of  abdominal  wounds.  More  bullets  pass  through 
the  body  than  other  projectiles  ;  the  reason  for  this  is  obvious. 
The  causes  for  retention  are  not  so  obvious,  and  I  have  known 
bullets,  fired  at  a  comparatively  short  distance,  remain  within 
the  body.  In  other  cases  the  bullet  may  have  passed  through 
the  earth,  and  so  have  had  its  velocity  diminished.  Ricochets 
account  for  a  certain  number. 

Shells. — These  show  a  high  proportion  of  retention,  which  is 
obviously  due  to  the  shape  of  the  fragments. 

Bombs  and  Grenades. — The  retained  fragments  are  strikingly 
in  excess  of  those  passed  out. 

The  large  proportion  of  retained  fragments  at  once  suggests 
the  possibility  of  armour  ;  and  no  doubt  armour  could  be 
devised  which  would  keep  out  many  fragments.  It  really  is 
more  or  less  a  question  of  what  the  soldier  is  able  to  carry.  One 
cannot  help  being  struck  with  the  resistive  power  of  an  ordinary 
book,  as  one  has  often  seen  projectiles  arrested  by  such  articles 
when  carried  by  the  soldier.  The  great  saving  of  life  effected 
by  the  steel  helmet  makes  one  hope  that  something  may  be 
produced  equally  efficacious  in  protecting  the  body.  Although 

2—2 


20 


War  Surgery  of  the  Abdomen 


we  could  not  expect  such  shields  to  be  supportable  and  at  the 
same  time  bullet-proof,  yet  many  bullets  have  lost  so  much 
velocity  that  they  are  retained,  and  the  number  of  bullets  is 
greatly  outnumbered  by  shell  and  bomb  fragments,  which  possess 
far  less  penetrative  power. 

Relative  Mortality  of  the  Different  Projectiles. 

The  following  table  shows  that  bullets  are  but  little  less 
dangerous  than  shells,  and  that  bombs  and  grenades  are  the 
least  noxious  :— 

TABLE  !!.• — Relative  Mortality  in  629  Cases. 


— 

Bullet. 

Shell 
Fragment. 

Shrapnel. 

Bomb  or 
Grenade. 

To  Base 

91 

105 

15 

60 

Died 

106 

154 

40 

58 

Total              .  .               197 

259 

55 

118 

General  Incidence  of  Wounds. 

The  charts  (Figs.  2  and  3)  were  made  by  plotting  the  entrance 
wounds  on  the  front  and  back  of  the  body  respectively.  The 
wounds  of  the  back  form  a  substantial  proportion  of  the  whole. 
There  is  a  tendency  for  the  wounds  to  collect  towards  the  sides, 
especially  on  the  back  of  the  body. 

The  comparative  absence  of  mid-line  wounds  is  also  seen  in 
Fig.  3,  which  represents  the  wounds  in  cases  too  bad  for  operation 
when  they  reach  a  Casualty  Clearing  Station.  This  distribution 
is  brought  about  by  the  presence  in  the  mid-line  of  the  spine 
and  the  great  vessels.  Men  shot  in  these  situations  die  on  the 
field  of  battle.  The  collection  of  wounds  towards  the  sides  of 
the  body  may  possibly  also  be  caused  by  the  fact  that  a  man's 
front  and  back  are  more  or  less  protected  in  the  trench,  while 
the  sides  of  the  body  are  open  to  enfilade  fire.  Many  of  the 
wounds  on  the  back,  especially  those  of  the  buttock  and  thigh, 


\   General  Review  of  Abdominal  Wounds     21 

are  due  to  bombs  and  rifle  grenades.    The  posterior  wounds  show 
a  larger  proportion  of  deaths  than  the  anterior. 

Influence  of  the  Position  of  Wound  and  Direction  of  Missile  on  Prognosis. 

CASES  TOO  SERIOUS  FOR  OPERATION. — The  chart  (Fig.  4    was 
obtained  by  plotting  the  entrance  wounds  and  the  track  of  the 


FIG  2. — Regional  incidence  of  wounds.     Front  view.     429  wounds.     Mortality 

53  per  cent. 

bullet,  when  known,  in  those  cases  which  arrived  at  the  Casualty 
Clearing  Station  in  such  a  condition  as  to  preclude  any  operative 
procedure  ;  they  all  died.  It  is  rather  striking  to  notice  how  the 
chart  becomes  blackened  in  a  fan-shaped  area,  the  apex  of  which 
is  the  left  hypochondrium.  There  is  a  comparative  absence  of 
mid-line  wounds  and  of  hypogastric  wounds.  This  must  not  be 
taken  as  meaning  that  hypogastric  wounds  are  not  dangerous, 
but  only  that  they  do  not  cause  such  injuries  as  to  render 
operation  useless.  The  side-to-side  wound  would  appear  to  be 


22 


War  Surgery  of  the  Abdomen 


the  most  dangerous  among  wounds  that  reach  an  operating  unit. 
This  seriousness  was  noticed  in  the  South  African  campaign. 

In  the  chart  (Fig.  3)  are  a  good  many  buttock  wounds.  From 
experience  gained  in  operating  on  such  cases,  we  must  regard 
lesions  of  the  pelvic  vessels  as  a  fairly  frequent  cause  of  death. 

The  mortality  that  accompanies  abdomino-thoracic  injuries 


FIG.  3. — Regional  incidence  of  wounds.     Back  view.     '222  wounds.     Mortality 

60  per  cent. 

is  possibly  explained  in  part  by  the  fact  that  such  wounds 
involve  this  dangerous  hypochondriac  area. 

Some  curious  instances  of  side-to-side  wounds  may  be  of 
interest  :  (1)  A  wound  of  the  upper  pole  of  the  left  kidney  and 
lower  pole  of  the  right,  wound  of  ascending  colon  ;  paraplegia  ; 
fatal.  (2)  Wound  of  the  right  kidney  and  spleen,  vertebra 
penetrated ;  no  paraplegia  ;  fatal  from  splenic  haemorrhage. 
(3)  Spleen  torn  on  its  anterior  edge,  left  kidney  perforated 
through  its  centre,  upper  pole  of  right  kidney  destroyed  ;  fatal 
(bullet).  (4)  Wound  of  the  left  kidney  and  the  posterior  surface 


A  General  Review  of.  Abdominal  Wounds     23 

of  the  ascending  colon  ;  fatal.  (5)  Hepatic  and  splenic  flexures 
alone  wounded  ;  fatal. 

In  sixty-eight  cases  a  post-mortem  was  performed  ;  Table  III. 
shows  the  injuries,  and  Table  IV.  the  number  of  times  individual 
organs  were  hit. 

In  nearly  every  case  there  was  much  blood  in  the  abdomen, 
and  in  thirteen  cases  the  note  is  made  that  death  was  due  to 


Transpyloric 
plane 


Orijice  of 
vermiform  process 


Trans  tubercular 
jo  lane 


FIG.  4. — Chart  of  cases  too  seriously  wounded  to  be  submitted  to  operation,  all  being 
fatal.  A  black  dot  represents  an  anterior  wound,  a  circle  a  posterior  wound  ; 
the  track  of  the  projectile  is  shown  by  a  line. 

haemorrhage.  In  only  five  cases  is  shock  noted  as  the  cause  of 
death,  viz.  :  (1)  One  perforation  of  ileum  with  a  shattered 
os  ilium.  (2)  Multiple  wounds  of  small  gut  ;  no  blood  in 
belly.  (3)  Shock  ;  no  other  details.  (4)  Wound  of  ileum  and 
sigmoid  ;  peritonitis  and  shock.  (5)  Wound  of  rectum  and  small 
gut. 

In  one  case  retroperitoneal  sepsis  was  noted  as  the  cause  of 
death.    In  only  three  instances  was  peritonitis  deemed  the  cause 


24  War  Surgery  of  the  Abdomen 

of  death.  The  number  of  times  the  small  gut  was  injured  is  the 
salient  feature  in  the  series,  and  perhaps  another  interesting 
point  is  that  the  stomach  figures  five  times.  Wounds  of  the 
solid  organs  were  responsible  for  death  in  twelve  instances. 

TABLE  III. — Showing  Injuries  in  Moribund  Cases. 

Stomach  and  kidney         . .          . .          . .          . .          . .  2 

,,           ,,     colon            . .          . .          . .          . .          . .  1 

„     liver             . .          . .                      . .          . .  .    1 

,,           ,,         ,.    spleen,  and  pancreas            . .          . .  1 

Small  gut 27 

,,         and  colon          . .          . .          . .          . .          .  .  4 

.,           ,,     rectum       . .          . .          . .          . .          . .  2 

,,           ,,     embolism  from  wounded  carotid           .  .  1 

Colon            . .          .  .          . .          .  .          . .          . .          . .  5 

,,      and  kidney  . .          . .          . .          . .          . .          . .  1 

Rectum       . .          . .          . .          . .          . .          . .          . .  2 

Liver            . .          . .  8 

,,     and  spleen                 . .          . .          . .          . .          . .  2 

„     kidney . .  1 

Spleen  and  kidney             . .          . .          . .          . .          . .  1 

Bladder 3 

Paraplegia  and  acute  dilatation  of  stomach      . .          . .  1 

Prolapse  of  stomach,  small  gut,  and  colon        . .          . .  1 

,,                 ,,           colon,  and  spleen ..          ..          ..  1 

,,            small  gut        . .          . .          . .          .  .          . .  1 

,,            spleen  and  splenic  flexure    . .          ,  .          . .  1 

Wound  of  internal  iliac  vein        . .          . .          . .          . .  1 

Total  cases      . .          68 

TABLE  IV. — Showing  the  Number  of  Times  Individual  Organs 

were  wounded. 

Stomach      . .          . .          . .          . .          . .        5 

Small  gut     . .          .  .          . .          . .  34 

Colon  10 

Spleen          . .          . .          .  .          . .          .  .        4 

Liver  . .          . .          . .          . .  13 

Kidney         . .          . .          .  .          . .          . .       5 

Rectum        . .          . .          . .          . .          . .        4 

Bladder 3 

Pancreas  1 


A  General  Review  of  Abdominal  Wounds     25 

CASES  RECOVERING  WITHOUT  OPERATION.' — Fig.  5  was 
obtained  by  plotting  the  entrance  wound  and  the  track  of  the 
missile,  when  known,  in  cases  that  recovered  without  operation. 
Most  of  these  wounds  lie  within  the  liver  area.  The  chart  also 
shows  wounds  in  various  other  parts  of  the  abdomen  ;  and 
their  recovery,  as  will  be  seen  later,  is  most  probably  due  to 


Orifice  of 
vermiform  process 


FIG.  5. — Chart  of  cases  that  recovered  without  operation.     Dots,  circles,  and  lines 
have  the  same  significance  as  in  Fig.  4. 

the  fact  that  the  hollow  viscera  had  escaped  although  the 
abdomen  had  been  penetrated. 

AYOUNDS     ABOVE     THE     TRANSPYLORIC     PLANE. AllterO-pOS- 

terior  wounds  in  this  region  are  among  the  least  serious  of  all 
abdominal  penetrations.  Side-to-side  wounds  are,  as  has  been 
seen,  serious,  especially  if  they  are  far  back.  Wounds  which 
enter  the  abdomen  from  above  downwards,  and  which  may  bo 
described  as  vertical,  are  also  serious.  Sometimes  one  has  great 
surprises,  and  one  case  may  be  mentioned  in  which  a  soldier 


26  War  Surgery  of  the  Abdomen 

was  shot  accidentally  by  a  revolver  bullet  which  entered  above 
the  blade-bone  and  was  taken  out  of  the  gastro-colic  omentum  ; 
no  hollow  viscus  was  injured,  and  the  man  made  a  complete 
recovery. 

Epigastric  Wounds. — In  the  mid-line  true  antero -posterior 
wounds  are  seldom  seen  in  hospital.  The  lesser  curvature,  the 
oesophagus,  and  a  large  portion  of  the  stomach  lie  within  this 
area.  Wounds  in  this  region  were  usually  accounted  as  stomach 
wounds,  and  recovery  often  reckoned  as  an  instance  of  spon- 
taneous healing.  Operation  has  proved  that  in  some  cases  the 
projectile  misses  the  stomach  and  perforates  the  gastro-hepatic 
omentum.  Naturally,  wounds  in  this  region  will  often  involve 
both  surfaces  of  the  stomach.  Epigastric  wounds  have  not 
maintained  their  reputation  as  favourable  lesions. 

Antero -posterior  Hypochondriac  Wounds. — On  the  right  the 
liver  will  be  perforated,  on  the  left  the  cardiac  area  of  the 
stomach  as  well  as  the  greater  curvature.  Towards  the  lateral 
line  of  the  body  the  kidneys,  spleen,  and  splenic  flexure  will  be 
involved  in  addition  to  the  liver  and  stomach. 

Oblique  Epigastric  and  Hypochondriac  Wounds. — When  the 
wounds  are  oblique  from  side  to  side,  no  distinction  can  be  drawn 
between  the  two  regions,  as  projectiles  traverse  both.  These 
wounds  are  decidedly  more  dangerous  than  antero-posterior 
wounds.  Indeed,  they  become  more  fatal  as  they  get  more 
oblique.  On  the  right  side  a  greater  length  of  liver  is  traversed, 
and  the  dangers  of  haemorrhage  and  sepsis  are  increased.  On 
the  left  the  stomach  is  perforated  more  and  more  obliquely, 
until  a  point  is  reached  where  the  axis  or  flight  of  the  bullet 
becomes  parallel  to  the  anterior  wall  or  greater  curvature.  The 
result  is  either  a  long  slit  or  a  double  hole  through  which  the 
contents  leak  freely.  The  spleen,  kidney,  and  splenic  flexures 
will  also  at  times  be  involved  with  the  stomach.  Wounds  of  the 
kidney  and  spleen  are  a  fairly  common  combination,  those  of  the 
stomach  and  spleen  a  rare  one. 

Vertical  Epigastric  and  Hypochondriac  Wounds. — These  are 
nearly  always  more  or  less  inclined  downwards  and  inwards, 
but  cases  occur  of  almost  vertical  wounds  in  which  both  the 
entrance  and  exit  wounds  are  on  the  anterior  surface  of  the  body 


A  General   Review  of  Abdominal  Wounds     27 

and  almost  vertically  above  one  another.  When  a  projectile 
passes  in  these  directions,  the  injury  of  the  liver  or  stomach  is 
complicated  by  one  of  the  colon  or  small  intestine,  for  the  missile 
often  passes  below  the  transpyloric  plane.  In  one  such  case 
both  the  antrum  of  the  stomach  and  the  transverse  colon  were 
almost  completely  cut  in  two.  Vertical  wounds  on  the  lateral 
surface  of  the  body  appear  at  first  as  thoracic.  On  the  right  side 
they  are  not  so  dangerous,  since  they  may  only  traverse  the 
liver  ;  but  on  the  left  they  may  wound  the  stomach,  spleen,  and 
liver. 

Posterior  and  Lateral  Wounds  of  Hypochondriac  Regions. — As 
usually  met  with,  these  are  single  entry  wounds.  Such  wounds 
between  the  left  axillary  lines  often  exhibit  the  omentum 
protruded  through  the  ribs.  On  the  left  the  spleen,  kidney, 
and  the  splenic  flexure  may  be  wounded,  and  therefore  such 
wounds  are  more  dangerous  than  those  occurring  on  the  right. 
They  are  difficult  to  treat,  as  access  to  this  region  is  not  easy, 
and  the  infiltration  of  the  retroperitoneal  tissue  renders  detection 
of  the  colon  perforation  difficult  even  if  the  spleen  and  kidney 
are  successfully  dealt  with.  Posterior  wounds  in  the  costo- 
vertebral  angle,  or  through  the  lower  ribs,  cause  similar  injuries 
to  those  on  the  lateral  body  surface. 

WOUNDS     BETWEEN     THE     TRANSPYLORIC     AND     INTERTUBER- 

CULAR  PLANES. — This  region  is  a  very  fatal  one  (see  Fig.  4). 
Above  the  umbilicus  the  injuries  resemble  to  a  considerable 
degree  those  met  with  above  the  transpyloric  plane,  but  below  the 
umbilicus  we  have  largely  to  deal  with  small  intestine  injuries. 

Antero  posterior  Wounds. — Again,  these  are  seldom  met  with  in 
the  mid-line.  On  either  side  of  the  spine,  in  the  upper  part  of 
the  region,  perforations  through  the  transverse  colon  are  met 
with,  and  are  usually  easily  dealt  with.  Lower  down,  but  still 
near  the  middle  line,  the  small  intestine  is  wounded,  and  the 
gravity  of  the  cases  at  once  rises.  In  the  lumbar  region,  wounds 
of  the  ascending  or  descending  colon  are  encountered.  If  the 
peritoneal  surface  alone  is  involved,  the  danger  is  not  so  great, 
provided  no  large  destruction  of  the  wall  has  taken  place. 
Wounds  of  the  left  lumbar  region  are  more  dangerous  than  those 
on  the  right,  for  here  the  coils  of  the  jejunum  overlie  the  great 


28  War  Surgery  of  the  Abdomen 

bowel.  There  is  another  point  of  interest  about  flank  wounds, 
and  that  is  the  possibility  of  the  escape  of  the  colon  or  perito- 
neum from  injury  owing  to  the  thickness  of  the  muscles  of  the 
abdominal  wall  at  this  point.  As  a  matter  of  fact,  the  colon, 
especially  the  descending,  when  seen  from  the  front  lies  farther 
from  the  lateral  line  of  the  body  than  might  be  supposed. 
Wounds  entering  the  back  in  this  region  are  more  fatal  on  the 
whole  than  those  that  enter  the  front  :  not  only  do  they  wound 
the  viscera,  but  they  plough  up  the  retroperitoneal  tissue,  or 
cause  it  to  be  stripped  by  blood  infiltration.  When  such  a  course 
is  taken  by  a  bullet  or  small  shell-fragment,  the  external  wound 
may  be  insignificant,  but  a  hidden  leak  into  the  retrocolic  tissue 
may  cause  death  before  sufficient  relief  has  been  given  by  a  free 
incision  or  a  colostomy. 

WOUNDS  BELOW  THE  INTERTUBERCULAR  PLANE. — These 
include  wounds  through  the  hips,  buttocks,  and  thighs.  All  are 
very  serious. 

Antero-posterior  Wounds. — In  the  hypogastric  region  these 
are  dangerous  on  account  of  small-gut  lesions.  Mid-line 
wounds  frequently  come  to  operation,  as  there  are  no  great 
vessels  to  cause  death  before  hospital  is  reached.  If  the 
bladder  is  full  it  will  be  involved,  but  it  is  a  somewhat 
remarkable  fact  that  such  injuries  are  not  very  common.  The 
pelvic  colon  and  the  rectum  may  be  injured.  Towards  the  side 
of  the  body,  in  the  iliac  regions,  wounds  of  the  caecum  and  iliac 
colon  are  encountered. 

Side-to-side  Wounds. — These  may  involve  the  caecum,  small 
gut,  and  pelvic  and  iliac  colons.  Such  injuries  are  very  danger- 
ous, the  small-gut  wounds  being  nearly  always  multiple.  The 
pelvic  vessels  may  also  be  injured,  and  cause  death  from  direct 
haemorrhage. 

Semi-vertical  Wounds. — In  the  Lancet  of  December  18th, 
1915, 1  called  attention  to  the  dangerous  nature  of  these  injuries, 
and  many  have  since  confirmed  this  opinion.  They  are  caused 
by  missiles  which  enter  the  buttock,  perineum,  or  thighs.  In 
the  early  days  of  the  war  a  wound  in  the  buttock  or  thigh  was 
often  unconnected  in  the  surgeon's  mind  with  the  possibility 
of  an  intestinal  lesion.  These  wounds  nearly  always  cause 


A  General   Review  of  Abdominal  Wounds     29 

multiple  injuries  of  the  small  intestine  ;  the  bladder  and  rectum 
are  also  involved.  Such  wounds  are  nearly  always  accom- 
panied by  pain  in  the  abdomen  soon  after  their  receipt.  The 
soldier  often  thought  that  he  had  been  hit  in  the  abdomen, 
while  the  surgeon  was  not  inclined  to  accept  this  diagnosis  ; 
the  fatality  of  such  cases  was  partly  due  to  the  abdominal  injury 
being  overlooked,  and  time  lost. 

Possibility  of  Escape  of  Viscera  in  Penetrating  Wounds. 

It  has  always  been  a  much  debated  point  as  to  whether  a 
projectile  could  traverse  the  peritoneal  cavity  without  wounding 
the  hollow  viscera.  Makins  held  that  it  was  possible  from  his 
experience  in  South  Africa.  Others  denied  the  possibility.  There 
has  never  been  any  doubt  that  the  liver  and  kidneys  could  be 
damaged  without  involving  other  organs.  The  point  that 
required  settling  was  the  escape  of  the  stomach  in  the  upper 
part  and  the  small  intestine  and  colon  in  the  lower.  Those  who 
believed  in  treating  abdominal  wounds  by  rest  and  starvation 
pointed  to  cures,  by  this  means,  of  patients  in  whose  cases  it 
appeared,  by  a  study  of  the  track  of  the  bullet,  that  a  hollow 
viscus  must  have  been  perforated.  Makins  held  that  there  was 
a  possibility  of  recovery  in  cases  of  colon  injury,  but  that  small- 
intestine  lesions  were  always  fatal. 

Until  quite  recently,  when  coeliotomy  became  the  routine 
treatment  of  abdominal  wounds,  a  proof  that  such  escape  was 
possible  was  almost  wanting.  The  classical  case  of  Cheatle's 
was  often  quoted  as  a  proof,  but  there  were  people  who  were  not 
convinced  by  it. 

Fig.  6  shows  a  chart  of  cases  in  which  the  abdomen  was 
opened  and  explored,  and  no  hollow  viscus  found  injured.  The 
abdominal  cavity  was  usually  full  of  blood.  This  blood  came 
from  two  sources  :  (1)  the  vessels  of  the  omentum,  mesentery, 
or  abdominal  wall  (deep  epigastric  usually)  ;  in  these  cases  the 
haemorrhage  was  arrested  by  ligature  of  the  vessel  :  (2)  from 
cracks  in  the  peritoneum  raised  'by  a  retroperitoneal  effusion  of 
blood  ;  here  little  beyond  clearing  the  abdomen  could  be  done, 
for  experience  has  shown  that  such  collections  of  blood  are  best 
left  alone. 


30  \Yar  Surgery  of  the  Abdomen 

In  many  cases  there  were  bruising  and  tears  of  the  peritoneal 
and  muscular  walls  of  the  stomach  or  intestine.  These  tears 
and  bruises  explain  the  cases  where  a  faecal  fistula  or  an  intra- 
peritoneal  abscess  has  appeared  some  time  after  the  receipt  of 
the  wound. 


Orifice  of 
vermiform  process 


Transjtyloric 
plane. 


Trans tubercular 
ft  lane 


FIG.  6.— rChart  of  cases  in  which  coeliotomy  was  performed  and  no  hollow  viscus 
found  injured.     Dots.,  circles,  and  lines  as  in  Fig.  4. 

The  Possibility  of  Spontaneous  Recovery  after  the  Perforation  of 

Hollow  Viscera. 

It  is  quite  true  that  people  do  recover  spontaneously  after 
wounds  of  the  hollow  viscera,  but  the  number  is  very  small. 
Those  that  recover  may  be  said  to  be  the  exceptions  that  prove 
the  rule.  The  following  are  instances  :— 

(1)  Healing  of  Stomach. — Makins  *  describes  a  case  in  which 

*  Journ.  of  the  Royal  Army  Medical  Corps,  January,  1916. 


A  General   Review  of  Abdominal  Wounds     31 

a  wound  of  the  posterior  surface  of  the  stomach  was  firmly  sealed 
to  the  pancreas  and  spleen  ;  death  resulted  from  secondary 
haemorrhage.  Lieutenant-Colonel  T.  R.  Elliott  and  Captain 
Herbert  Henry  have  also  described  cases  of  spontaneous 
healing.  I  myself  have  seen  a  healed  wound  of  the  stomach 
in  a  patient  who  succumbed  to  other  injuries.  Lastly, 
Captain  Green-Armytage  actually  closed  the  abdomen  in  a 
case  where  a  hole  in  the  stomach  was  impossible  of  suture, 
and  a  cure  resulted.  Although  such  healing  does  result,  it  must 
be  looked  upon  as  more  of  academic  than  of  practical  interest. 
No  surgeon  would  nowadays  use  such  cases  as  an  argument  in 
favour  of  abstention. 

(2)  Healing  of  Colon. — There  have  been  frequent  instances  of 
recovery  after  wounds  of  the  vertical  colons,  as  has  been  insisted 
on  by  Makins,  who  attributes  such  a  favourable  result  to  the 
intense  local  reaction  produced  by  the  contents  of  this  portion 
of  the  bowel. 

(3)  Healing  of  Small  Intestine. — For  the  history  of  the  follow- 
ing remarkable  case  I  am  indebted  to  Surgeon-General  Bowlby 
and  Captain  Bell : — A  soldier  was  shot  from  side  to  side  through 
the  body  at  the  battle  of  Loos.    He  was  not  operated  on,  and 
recovered.    There  was  nothing  special  about  his  convalescence. 
He  was  again  shot  in  the  abdomen  in  the  battle  of  the  Somme 
and   was   operated   upon.     When  the   abdomen  was   opened, 
several  perforations  of  the  small  intestine  were  found  in  the 
neighbourhood   of  a  mass   of  adhesions.     The  wounded   and 
adherent  segments  were    excised,  and  the  man  made  a  good 
recovery.     On  slitting  up  the  adherent  coils  an  entero-entero- 
stomy  was  found  between  two  adjacent  loops  ;    in  addition, 
there  were  several  small  herniated  diverticula  of  the  mucous 
membrane,  obviously  pointing  to  closure  of  the  previous  penetra- 
tions.    This  case  is  of  interest  because  the  process  of  healing 
corresponds  to  that  which  Captain  H.  Drummond  has  shown  to 
be  the  case  when  the  intestines  of  rabbits  are  perforated,  and 
put  back  without  suture.     The  herniated  mucous  membrane 
remains  herniated,  and  gradually  becomes  covered  with  a  layer 
of   lymph,    which    slowly    organises    and    seals    the   hole,    the 
herniated  mucous  membrane  still  forming  a  diverticulum. 


32  \Yar  Surgery  of  the  Abdomen 

Rupture  of  Viscera  outside  the  Actual  Course  of  the  Projectile. 

(1)  Rupture  of  Viscera  by  Contusion  of  the  Abdomen. — As  in 
civil  life,  one  meets  with  a  fair  number  of  abdominal  injuries 
caused   by  horse  kicks.     Others   are   caused  by  falling  in  of 
dug-outs,  by  burial  of  men  by  shell  explosions,  and  by  blows  of 
fragments  of   wood  which   are  hurled   about.     They   present 
nothing  out  ofHhe  common,  and  the  injuries  seen  are  the  same  as 
some  in  civil  life.   Captain  J.  B.  Hay  craft  had  one  case,  which 
may  be  mentioned,  in  which  the  post-mortem  examination  on  a 
man  who  died  after  such  burial  showed  numerous  contusions  of 
the  small  intestine,  without  rupture. 

(2)  Similar  injuries    are  caused    by    large    shell    fragments, 
usually  shell  caps,  and  several  cases  of  the  latter  injury  have 
been  seen  in  which  rupture  of  the  intestine  was  accompanied 
by   extensive   contusions.      Some  years   ago   Makins   wrote   a 
paper  on  this  subject,  and  he  came  to  the  conclusion  that  such 
injuries  are  caused  by  the  bowel  being  caught  between  the 
unyielding  posterior  abdominal  wall  and  the  oncoming  object. 
This  supposition  is  strengthened  by  the  association   of  bruises 
with  perforations  in  the  case  above  quoted. 

(3)  Cases  in  which  the  Viscera  are  damaged  by  Indriven  Bone 
Fragments. — (a)  There  are  many  cases  of  injury  to  the  liver  and 
spleen  by  the  driving  in  of  fractured  ribs,    (b)  The  caecum,  the 
ascending  and  descending  colon,  and  also  the  small  gut  in  the 
pelvis,  are  all  apt  to  be  injured  by  small  bony  spicules  driven  in 
through  the  peritoneum.    Although  the  projectile  itself  does  not 
penetrate  this  membrane,   it  is  important  to  remember  this 
possibility,  because  when  such  wounds  are  explored  it  is  most 
probable  that  the  small  holes  caused  by  the  bony  fragments  will 
be  overlooked,  and  the  peritoneum  assumed  to  be  inviolate. 

(4)  Rupture  of  Solid  Organs  by  Indirect  Violence  of  a  Passing 
Projectile. — Such  injuries  are  not  uncommon.      Fig.  7  shows  a 
picture  of  a  kidney  in  which  many  cracks  in  the  capsule  were 
produced  by  a  missile  which  did  not  touch  the  organ.     The 
spleen  is  often  ruptured   in  this  manner,  and    sometimes   the 
liver.     In  one  case  the  diaphragm  was  intact,  but  on  opening 
the  peritoneum  much  blood  escaped,  and  there  was  an  extensive 


A  General  Review  of  Abdominal  Wounds 


33 


tear  in  the  spleen.  In  another  case  the  diaphragm  was  ruptured 
over  a  small  area,  the  blow  being  a  glancing  one.  There  was  a 
corresponding  wound  on  the  outer  surface  of  the  spleen,  and  from 
this  wound  there  ran  in  all  directions  radiating  fissures  in  the 
capsule,  showing  that  the  spleen  had  been  burst  by  the  indirect 
force  exerted  upon  it. 


IMC.  1. — Kidney :  indirect  effects  of  gunshot — organ  fissured,  concentric  fissures 
run  across  the  intima  of  the  renal  artery.  Bullet  entered  left  buttock, 
traversed  sacrum  and  fifth  lumbar  vertebra,  and  passed  out  through  right 
psoas,  keeping  behind  the  colon ;  the  track  was  quite  clear  of  the  colon  and 
kidney.  (Specimen  prepared  by  Captain  J.  S.  Dunn.) 

(.'))  Rupture  of  .Hollow  ()>\<I<IHX  />//  Indirect  1'iolcnce. — Cases  of 
this  class  have  been  reported  by  Owen  Richards,  John  Fraser, 
J.  W.  Dew.  and  others. 

(a)  Rupture  of  the  intestine  by  a  bullet  without  penetration. 
The  first  case  was  that  of  a  man  whose  recti  were  divided 
almost  completely  by  a  bullet.  The  wound  was  explored,  anil 

W.S.A.  3 


34  War  Surgery  of  the  Abdomen 

the  posterior  rectus  sheath  found  intact.  As  there  were  no 
symptoms,  the  abdomen  was  not  opened  ;  the  man  died.  At 
the  post-mortem  a  careful  search  failed  to  show  any  rupture  of 
the  peritoneum.  There  were  three  holes  in  the  small  intestine 
which  lay  immediately  under  the  wound  in  the  abdominal  wall, 
showing  the  gut  had  not  moved,  although  more  than  twenty- 
four  hours  had  elapsed  since  the  receipt  of  the  injury.  Eraser's 
case  was  that  of  a  man  wounded  by  a  piece  of  shell  in  the  right 
iliac  fossa,  the  caecum  being  found  bruised,  and  a  small  hole  in 
the  mesenteric  border  of  the  ileum.  In  Dew's  case  the  projectile 
had  cut  through  all  the  abdominal  wall  except  the  peritoneum, 
through  which  the  caecum  could  be  seen.  As  there  were  no 
symptoms,  the  abdomen  was  not  opened,  but  the  man  died  from 
a  ruptured  ileum.  Stevenson,  Shaw,  and  Mackenzie  have 
described  a  rupture  of  liver  and  jejunum  by  a  missile  that  did 
not  open  the  abdomen. 

It  would  seem  that  these  ruptures  may  be  caused  in  two 
possible  ways  :  (1)  When  an  object  such  as  the  abdomen  and  its 
contents,  made  up  of  layers  of  varying  toughness,  is  sharply 
hit,  more  friable  layers  underneath  may  give  way,  while  the 
more  resisting  overlying  layers  remain  intact.  (2)  This  may 
be  termed  the  "  paper-bag  "  theory,  the  viscus  being  ruptured 
by  a  smart  blow  in  a  similar  way  to  that  in  which  an  inflated 
paper  bag  is  burst  on  being  hit.  There  is  no  proof  that  this 
happens,  but  it  is  rather  a  seductive  theory.  The  following 
case  of  .1.  Fraser's  is  interesting  in  this  connection  :  A  bullet 
penetrated  the  abdomen  just  below  the  umbilicus  ;  there  were 
no  symptoms  at  first,  but  when  they  arose  later  on,  coeliotomy 
showed  a  ruptured  bladder.  The  bladder  was  apparently  out 
of  the  direct  line  of  the  projectile. 

There  is  another  possibility  which  must  not  be  lost  sight  of:  a 
man  may  fall  to  the  ground,  or  against  some  object,  when  he  is  hit, 
and  the  ruptured  intestine  be  due  to  the  blow  thus  produced,  and 
not  to  the  actual  missile  which  was  the  indirect  cause  of  the  fall. 

Mechanism  of  Wound  Production  after  Penetration. 

The  multiplicity  of  the  wounds  of  the  small  intestine  has 
raised  some  doubt  as  to  their  method  of  production,  especially 


A  General  Review  of  Abdominal  Wounds     35 

in  the  case  of  bullets,  where  widely  different  types  of  wound  are 
seen.  The  question  arises  whether  a  bullet  pursuing  a  straight 
course  can  cause  these  injuries,  or  whether  we  must  invoke  a  rota- 
tion of  the  bullet,  or  a  bursting  effect.  If  a  bullet  is  rotating 
quickly  on  a  transverse  axis,  it  could  easily  produce  complete 
division  of  the  gut,  but  if  it  is  rotating  quickly  enough  to  pro- 
duce such  injuries,  it  is  hard  to  see  how  it  could  at  the  same 
time  produce  small  perforations.  Some  support  is  given  to  the 
rotation  theory  by  the  retention  of  many  bullets  ;  one  knows 
that  their  flight  is  unstable  at  the  end.  If  the  rotation  theory 
is  correct,  one  ought  to  have  some  evidence  of  this  rotation  at 
the  entrance  and  exit  holes.  As  a  fact,  it  is  impossible  to 
establish  any  relations  between  the  size  of  the  entrance  and 
exit  wounds  in  the  skin  and  the  amount  of  damage  done  to  the 
intestine.  As  to  the  possibility  of  a  bursting  effect  (paper-bag 
theory)  it  is  impossible  to  make  any  definite  statement.  In  a 
case  operated  on  by  Captain  Hamilton  Drummond  there  was 
a  rupture  of  the  small  intestine  between  the  leaves  of  the 
mesentery  which  was  not  found  until  the  intestine  was  laid 
open.  The  position  of  the  rupture  was  outside  the  track  of 
the  bullet  (see  also  Fraser's  case  of  ruptured  bladder).  One 
must  remember,  however,  that  the  intestine  is  not  greatly 
distended  by  either  gaseous  or  fluid  contents.  It  seems  almost 
impossible  to  believe  that  anything  of  the  nature  of  a  hydraulic 
or  pneumatic  effect  could  be  produced.  In  this  connection  the 
following  case  is  pertinent  :  A  soldier  was  shot  through  the 
abdomen,  the  muzzle  of  the  rifle  being  in  contact  with  the  body. 
The  entrance  wound  was  close  beside  the  umbilicus,  and  the 
exit  wound  at  a  corresponding  point  behind.  The  bullet  passed 
by  the  side  of  the  vertebral  column  and  made  three  type  lesions 
in  the  jejunum.  He  was  promptly  operated  on,  and  made  a 
perfect  recovery.  If  any  pneumatic  or  hydraulic  effect  is  to  be 
expected,  it  should  have  been  found  in  this  case.  I  am  rather 
inclined  to  think  that  these  different  types  of  wound  are  caused 
by  the  varying  state  of  distension  of  the  small  gut.  As  is  well 
known,  one  meets  with  lengths  of  the  small  intestine  alter- 
nately distended  with  air  and  collapsed.  If  the  bullet  strikes 
a  distended  portion,  it  will  perforate  it  or  cut  a  hole  in  it.  If  it 

3—2 


36  War  Surgery  of  the  Abdomen 

strikes  a  portion  which  is  collapsed,  the  intestine  is  so  small 
that  the  bullet  is  large  enough  in  diameter  to  divide  both 
coats  the  whole  breadth  of  the  bowel. 

Some  support  is  given  to  this  assumption  by  the  behaviour 
of  the  large  gut.  Perforations  are  here  much  more  common 
than  large  tears  or  complete  division.  When  complete  division 
does  occur  it  is  in  the  portions  of  the  gut  that  are  often  found 


FIG.  8. — Small  intestine  divided  in  seven  places  by  a  rifle  bullet.  Small  wound  of 
entrance  in  epigastric  region.  Bullet  lay  free  within  abdominal  cavity.  Parts 
resected.  Patient  died  a  few  hours  after  operation.  (Brit.  Journ.  of  Surgery.) 

small  and  collapsed,  namely  the  transverse  and  descending  and 
pelvic  colons.  The  ascending  colon  and  hepatic  flexure  nearly 
always  show  perforations. 

In  considering  this  subject  great  interest  attaches  to  a 
lecture  by  Professor  S.  G.  Shattock,  an  abstract  of  which,  as  it 
appeared  in  the  British  Medical  Journal,  December  15th,  1017, 
is  appended  below.* 

*  For  the  complete  lecture  ><•<•  I'roceedings  of  Royal  Snciilij  of  Medicine,  1917. 


A  General  Review  of  Abdominal  Wounds     37 

Professor  S.  G.  Shattock,  F.H.S.,  observed  that,  from  the 
strictly  pathological  standpoint,  the  new  factor  introduced 
into  gunshot  injuries,  as  injuries,  was  the  velocity  of  the 
penetrating  body  ;  they  were  otherwise  contused  and  infected 
wounds  like  those  produced  by  other  foreign  bodies,  although 
their  number  and  variety  gave  them  special  surgical  features. 
Under  the  term  "  explosive  effect  "  more  than  one  thing  was 
included  :  it  was  applied  (1)  to  the  increase  of  damage  due  to 
shattering  of  the  bullet,  (2)  to  the  additional  injury  resulting 
from  the  comminution  of  a  bone  and  the  dispersal  of  its  frag- 
ments, and  (3)  to  the  damage  resulting  from  the  high  velocity 
of  the  missile.  The  last  alone  possessed  any  special  patho- 
logical interest.  It  had  been  asserted  (Professor  Dr.  K. 
Stargardt)  that  the  British  bullet  was  an  expanding  one,  in 
consequence  of  the  core  being  composed  of  aluminium  at  the 
point,  and  elsewhere  of  lead  ;  that  on  striking  (bone  at  least) 
the  momentum  of  the  lead  carried  this  forwards  over  the  harder 
aluminium,  and  so  split  the  mantle.  In  order  to  test  this  the 
author  had  had  recourse  to  the  following  experiment  :  The 
bullet  was  fired  at  a  distance  of  20  feet  through  a  sternum 
into  cotton  waste,  from  which  it  was  recovered  without  having 
struck  any  second  object.  The  sternum  was  selected  in  order 
to  obtain  a  direct  hit.  The  bullet  was  found  to  have  undergone 
no  distortion  whatever.  Two  sterna  were  then  spliced  together 
and  shot  through  in  the  same  way  ;  the  bullet  on  recovery 
was  found  quite  undamaged.  In  solid  organs  the  results  of 
high  velocity  were  best  seen  in  the  liver  when  perforated  by 
rifle  bullets  at  close  range.  The  typical  injury  was  a  perforation 
accompanied  with  radial  fissuring  of  wide  extent.  Even  here 
the  elimination  of  extraneous  factors,  such  as  obliquity  of 
impact,  or  turning  of  the  missile  in  transit,  damage  due  to  the 
introduction  of  clothing,  could  only  be  effected  by  experiment. 
In  firing  through  suspended  sheep  livers  at  20  feet  with  a  service 
rifle  and  pointed  bullet,  this  was  the  form  the  injury  took  ;  the 
mechanical  action  of  gas  produced  by  explosion  was  eliminated 
by  the  distance.  In  analysing  the  physics  of  this  result  the 
wave  of  compressed  air  produced  by  the  bullet  (demonstrated 
by  Professor  Vernon  Boys  in  instantaneous  photographs)  was 


38  \Y;ir  Surgery  of  the  Abdomen 

wholly  negligible.  The  speaker  had  found  that  if  tense  screens 
of  tissue  paper  were  shot  through  at  20  feet  with  a  service  rifle, 
the  hole  was  but  little  larger  than  the  bullet ;  were  the  air  wave 
of  any  moment,  the  paper  would  obviously  have  been  widely 
rent.  Sir  Victor  Horsley,  in  commenting  upon  the  cavitation 
produced  in  his  experiments  of  firing  into  clay,  attributed 
more  importance  to  the  spin  of  the  bullet  (centrifugal  action) 


Fin.  9. — Rupture  and  laceration  of  the  right  lobe  of  the  liver  by  bullet  discharged 
at  short  range.  It  perforated  the  right  hypogastric  region  from  before  backwards.. 
Soldier  died  of  haemorrhage.  (Brit.  Journ.  of  Surgery.) 

than  to  its  forward  movement.  The  speaker  had  carefully 
inspected  all  the  plaster  casts  made  from  the  clay  in  these 
experiments,  and  was  unable  to  find  the  evidence  of  such  rota- 
tion ;  the  coarser  ridges  (representing  shallow  fissures  in  the 
clay)  as  well  as  the  finer  markings  were  longitudinal.  The  turn  of 
the  present  British  bullet  was  only  one  in  10  inches,  yet  explosive 
effects  were  observable  in,  for  example,  the  sheep  livers  before 
referred  to,  where  the  thickness  was  only  1|  inch,  which  would 


A  General  Review  of  Abdominal  Wounds     39 

reduce  the  rotation  to  less  than  a  fifth.    In  only  one  specimen — 
in  the  collection  on  view  in  the  Royal    College  of  Surgeons — 
were  the  divergent  fissures  curved  ;    here  the  bullet  had  tra- 
versed the  body  of  the  third  lumbar  vertebra  first,  and  must 
have  had  some  altogether  exceptional  twist  imparted  to  it.    The 
question  was  thus  reduced  to  one  of  forward  velocity.    This  was 
well  shown  in  the  liver  by  the  fact  that  in  perforations  caused 
by  shell    fragments  at    low  velocity  a  patulous  tunnel  alone 
resulted.     The  same  difference  was  beautifully  demonstrated 
in  Horsley's  casts,  where  the  distal  half  was  only  of  the  calibre 
of  the  bullet,  the  explosive  or  dilating  effect  being  limited  to  the 
proximal.     In  the  case  of  the  clay,  the  ready  entrance  of  air 
from  behind  allowed  of  its  cavitation  ;    in  the  liver,  where  this 
was  out  of  the  question,  the  cavitation  was  represented  by  radial 
fissuring  produced  by  the  passage  of  the  wave  through  an  in- 
compressible semi-solid  medium.     In  hollow  organs  the  produc- 
tion of  explosive  effects  depended  upon  their  contents,  other 
things  being  equal.     Such  effects  from  rifle  bullets  were  not 
observed  in  the  stomach  or  intestines  by  reason  of  the  com- 
pressible air  and    gas  which    they  contained,  nor  in  the  lung, 
for  the  same  reason.     The  contusion,  unattended  with  breach 
of  surface,  found  not  rarely  in  such  organs,  was  possible  from 
their  extreme  mobility  and  compressibility.     The  longitudinal 
wounds  produced  at  times  in  the  intestine  by  intact  bullets 
were  explained  by  the  wall  having  been  struck  axially.    In  the 
case  of  the  bladder,  the  contents  of  which  were  incompressible, 
explosive   results   were   now   and   then   encountered.      In   the 
collection  there  was  a  bladder  perforated  by  a  rifle  bullet  which 
entered   through   the   buttock   without   fracturing   bone,    and 
eventually  escaped  above  the  pubes  ;    in  the  posterior  wall  of 
the  bladder  was  an  entry  admitting  the  finger  ;    the  anterior 
wall  (exit)  was  rent   from  top   to  bottom.      The  speaker  had 
obtained  similar  explosive  results  by  firing  through  ox  bladders 
distended    with   water,   a  service  rifle   being  used  at   20  feet. 
The  result  was  a  simple  hydrodynamic  one,  and  due  to  the  wave 
imparted  to  a  mobile  and  incompressible  fluid  in  a  confined 
space.     If  the  bladder  was  empty,  or  only  lightly  filled,  the 
rending  on  the  far  side  did  not  take  place.    In  arteries  and  veins 


40  War  Surgery  of  the  Abdomen 

no  hydrodynamic  effect  was  observable,  whether  in  unilateral 
or  bilateral  perforation.  Its  absence  was  possibly  due  to  the 
indefinite  continuity  of  fluid  above  and  below  the  stricken  spot 
and  to  the  remarkable  strength  of  both  kinds  of  vessels.  The 
speaker  had  been  unable  to  produce  either  macroscopic  or  micro- 
scopic damage  of  the  inner  or  middle  coats  of  the  human 
common  iliac  artery  under  the  highest  pressure  that  could  be 
exerted  with  a  dissecting-room  syringe.  In  regard  to  the  skeleton, 
the  rigidity  of  the  structure  concerned  was  a  complicating  factor. 
If  the  upper  part  of  the  shaft  of  the  tibia  was  compressed  over 
a  small  area  in  a  vice,  however  slowly  the  compression  was  made, 
extensive  comminution  and  fissuring  ensued  far  beyond  the  spot 
compressed.  Nevertheless  the  same  rule  held  :  the  greater  the 
velocity  of  the  missile  the  greater  the  damage. 

The  classical  example  of  explosive  effect  was  the  well-known 
widespread  comminution  of  the  skull  when  bilaterally  perforated 
by  a  rifle  bullet  at  close  range.  The  effects  due  to  the  gas  of 
explosion  had,  of  course,  to  be  excluded.  The  results  of  suicidal 
shooting  were  thus  liable  to  lead  to  false  conclusions  :  a  rifle 
fired  into  the  mouth  with  blank  cartridge  would  produce 
extensive  comminution.  This  factor  was,  however,  easily 
eliminated  ;  the  speaker  had  found,  too,  that  sheep  skulls  with 
the  brain  in  situ  underwent  extensive  comminution  when  shot 
through  at  20  feet  with  a  service  rifle,  the  foramen  magnum 
being  freely  open.  The  result  was  not,  properly  speaking, 
hydraulic,  but  hydrodynamie — that  is,  it  was  not  due  to  a 
generalised  and  equable  internal  pressure,  but  to  the  sudden 
impact  of  the  incompressible  cerebral  substance  against  the 
interior  of  the  cranium.  A  simple  experiment,  devised  by  the 
speaker,  would  emphasise  this.  A  large,  flat-sided  "  cocoa  tin  " 
was  shot  through  in  the  empty  state  at  20  feet  with  a  service 
rifle  ;  a  circular  entry  and  exit  of  about  the  diameter  of  the 
bullet  resulted.  A  second  tin  was  filled  with  water  and  shot 
through,  the  lid  being  removed ;  the  entry  was  small  and 
circular,  the  exit  widely  split,  with  large  triangular  flaps  of  the 
metal  completely  everted.  The  speaker  had  obtained  pro- 
nounced explosive  effects  also  in  sheep  skulls  inverted  and  filled 
with  water,  the  foramen  magnum  being  freely  open  ;  if  the 


A  General  Review  of  Abdominal  Wounds     41 


skull  was  shot  through  in  the  empty  condition,  a  circular  entry 
and  exit  alone  resulted. 

Comparative  Frequency  of  Wounds  in  the  Different  Viscera. 
The  following  table  gives  some  idea  of  the  relative  frequency 
with  which  different  organs  in  the  abdomen  are  wounded  : — 

TABLE  V. — Relative  Frequency  with  which  Different  Abdominal 
Organs  are  wounded.     From  a  Total  of  965  Cases. 


Viscus. 

No.  of  Times 
wounded. 

Viscus. 

No.  of  Times 
wounded. 

Small  gut 
Colon 

363 
252 

Spleen 
Bladder   .. 

54 
45 

Liver 

163 

Rectum 

21 

Stomach 

82 

Pancreas 

5 

Kidney 

74 

Ureter 

3 

State  of  the  Alimentary  Canal  in  respect  of  its  Contents. 

(1)  Stomach. — The  amount  of  food  in  the  stomach  is  dependent 
on  the  time  that  has  passed  between  the  last  meal  and  the  time 
of  wounding.     The  escape  of  contents  depends  on  this,  and  on 
the  size  and  situation  of  the  wound.     If  the  wound  is  a  small 
one,  and  near  the  lesser  curvature  or  the  cardiac  end,  there  will 
be  little  found  in  the  abdomen  ;  if,  on  the  other  hand,  the  wound 
is  large,  and  near  the  greater  curvature,  extravasation  may  be 
very  considerable.     It  is  only  in  connection  with  the  stomach 
that  free  gas  has  been  seen  to  escape  from  the  wound  or  to  be 
present  in  the  abdomen. 

(2)  The  Small  Intestine. — The  small  intestine  is  usually  empty, 
and  it  is  hard  to  fix  any  definite  relation  between  the  amount  of 
its  contents  and  the  time  of  the  last  meal.     It  is  in  a  very 
favourable  condition  from  a  surgical  point  of  view,  even  more  so 
perhaps  than  after  the  elaborate  preparation  which  has  been  till 
recently  the   rule  in  civil  operative  practice.     The  collapse  of 
the  gut  is  not  due  to  escape  of  gas,  for  free  gas  is  not  found  in 
the  abdomen. 

The  usual  absence  of  any  large  amount  of  intestinal  contents 
s  to  be  due  to  a  more  rapid  passage  of  food  along  the 


42  War  Surgery  of  the  Abdomen 

tube  than  is  usually  considered  normal,  or  else  to  a  very 
complete  digestion.  Otherwise,  considering  the  number  of  cases 
treated  at  various  intervals  after  meals,  the  presence  of  contents 
should  be  more  frequent.  It  is  the  absence  of  contents,  more 
than  anything  else,  that  accounts  for  the  little  extravasation. 
Should  the  intestine  be  loaded,  there  is  a  large  escape. 

In  one  case  it  was  possible  to  get  the  exact  time  of  the  last 
meal.  A  man  had  a  dinner  of  bully-beef  and  Clarke's  beans  at 
1  p.m.  ;  he  was  hit  at  6  p.m.,  and  operated  on  at  10  p.m.  All 
evidence  goes  to  show  that  after  a  wound,  digestion  and  vermi- 
cular movements  cease,  so  that  one  can  assume  the  state  of  the 
intestine  at  10  p.m.  was  the  same  as  that  at  6  p.m.  The  operation 
showed  that  the  man  was  wounded  3|  feet  from  the  caecum,  and 
here  the  bowel  contained  much  fluid  and  solid  matter,  including 
Clarke's  beans,  which  were  extravasated  to  a  large  extent.  This 
case  was  under  the  care  of  Captain  H.  Drummond. 

Another  interesting  observation  was  made  by  Captain  John 
Fraser.  A  party  of  soldiers  was  shelled  in  billets  just  after  the 
midday  meal,  which  consisted  of  large  quantities  of  tea.  There 
were  several  cases  of  abdominal  wounds.  The  amount  of  fluid 
in  the  abdomen  in  some  cases  of  wounded  small  gut  was  remark- 
able, and  in  contrast  to  the  usual  condition.  It  looked  as  if  the 
fluid  contents  had  passed  rapidly  into  the  small  intestine.  The 
stomachs  themselves — to  judge  by  one  case,  at  all  events — were 
still  full  of  food.  It  is  interesting  to  note  that  extravasation  is 
apparently  more  common  in  vegetarians  than  in  meat  eaters. 
(Major  C.  H.  Barber,  I. M.S.,  Gunshot  Wounds  of  the  Abdomen 
during  the  Siege  of  Kut :  Lancet,  Jan.  20,  1917.) 

(3)  The  Large  Intestine. — This  is  often  loaded,  and  presents  a 
great  contrast  to  the  small  intestine  in  this  respect.  This  fact, 
no  doubt,  is  due  to  the  sedentary  life  in  the  trenches.  The 
loaded  state  of  the  bowel  may  have  some  relation  to  the  infec- 
tivity  of  the  contents.  On  the  other  hand,  a  constipated  condi- 
tion tends  to  limit  the  escape  of  the  contents. 

State  of  the  Alimentary  Canal  in  respect  of  the  Nervo-Muscular 

Mechanism. 

When  considering  this  subject  a  sharp  distinction  must  be 
drawn  between  the  appearances  seen  before,  and  after  sepsis 


A  General  Review  of  Abdominal  Wounds     43 

has  produced  its  effects  on  the  intestine.     It  is  with  the  former 
that  we  are  at  present  concerned. 

The  Stomach. — This  is  often  normal  both  as  regards  its  size  and 
the  thickness  of  its  walls.  On  the  other  hand,  it  is  by  no  means 
rare  to  find  it  dilated.  This  dilatation  is,  as  a  rule,  of  moderate 
dimensions,  but  may  be  of  considerable  extent,  and  occasionally 
a  condition  of  acute  dilatation  is  present.  This  last  condition 
is  seen  both  in  peritoneal  and  retroperitoneal  wounds,  and  with 
and  without  spinal  injury.  Apart  from  actual  dilatation  seen  in 
the  course  of  operation,  many  cases  after  operation  present 
the  clinical  symptoms  of  the  condition,  which  is  relieved,  as  a 
rule,  by  stomach  lavage,  but  sometimes  ends  fatally. 

An  experiment  performed  by  Captain  H.  Drummond  and 
myself  may  be  of  interest  in  this  connection.  A  dog  was  given  a 
weighed  meal  containing  bismuth.  A  skiagram  showed  that  the 
organ  emptied  itself  in  six  hours.  The  experiment  was  repeated, 
with  the  addition  that  the  animal  was  anaesthetised  for  half 
an  hour.  There  was  no  delay  in  the  emptying  of  the  organ. 
Another  experiment  was  performed  similar  to  the  last,  but  in 
this  instance  a  resection  and  suture  of  intestine  was  performed. 
The  stomach  had  not  begun  to  empty  itself  in  six  hours. 

The  following  case  shows  that  the  loss  of  motile  power  is  not 
altogether  dependent  on  a  penetrating  wound  :  An  officer  had 
his  dinner  at  7  p.m.  Immediately  afterwards  he  took  his  platoon 
into  the  trenches.  On  the  way  up  some  obstruction  occurred  in 
the  communication  trench,  and  the  officer  got  out  of  the  trenc'.i 
to  put  matters  right.  His  femur  was  shattered  by  a  bullet  at 
10  p.m.  The  next  morning  at  11  a.m.,  having  had  no  food  in 
the  interval,  he  was  given  an  anaesthetic  that  the  wound  might 
be  treated  in  the  ordinary  way.  He  vomited  his  dinner  prac- 
tically unaffected  by  digestion. 

The  Small  Intestine. — This  presents  alternate  lengths  of 
moderate  distension  and  collapse,  and  on  the  whole  the  calibre 
of  the  tube  is  on  the  small  side  of  that  usually  seen  in  civil 
practice.  Sometimes  this  condition  is  exaggerated,  and  the 
appearance  of  the  abdominal  contents  when  first  seen  on  opening 
the  belly  is  comparable,  as  Fraser  has  said,  to  that  of  a  formal  in 
body.  Very  occasionally  a  wounded  segment  of  the  gut  presents 


44  War  Surgery  of  the  Abdomen 

a  local  dilatation  at  the  lesion   (sec  Fig.  11).     Sometimes  the 
upper  jejunum  shares  in  the  dilatation  of  the  stomach. 

The  intestines  remain  motionless  a  considerable  time  after 
injury.  This  is  shown  by  the  fact  that  when  the  missile  has 
taken  a  comparatively  superficial  course,  and  wounded  the  gut 
as  it  lies  against  the  anterior  belly  wall,  the  injured  part  is  still 
found  in  the  same  place  after  a  considerable  interval.  The 
same  thing  has  been  noted  in  those  cases  where  the  gut  has 
been  ruptured  without  abdominal  penetration,  and  death  has 
ensued  (see  page  33).  I  have  seen  the  wounded  gut  still  in 
the  place  in  which  it  was  hit  after  thirty-six  hours.  The 
adhesions  that  quickly  form  after  wounding  no  doubt  anchor  it 
in  place  after  motility  has  reappeared.  Sir  William  Watson 
Cheyne  described  a  similar  case  in  the  South  African  War, 
where  the  gut  remained  in  position  after  three  days. 

Drummond  and  Fraser  have  raised  the  interesting  point  as 
to  whether  an  extensive  injury  of  the  small  intestine  may  not, 
to  a  certain  degree,  assist  in  its  own  cure  by  causing  a  more 
profound  paralysis  than  does  a  more  trivial  injury. 

It  is  at  present  impossible  to  say  definitely  how  long  on  the 
average  the  gut  remains  paralysed  ;  the  only  other  observation 
bearing  on  this  subject  is  that  peristalsis  has  been  seen  in  the 
jejunum  eleven  hours  after  injury. 

It  is  possible  that  a  persistence  of  the  traumatic  paralysis  of 
the  gut  is  the  source  of  trouble  after  a  resection,  and  two  cases 
apparently  of  this  nature  have  been  reported  by  Richards  anil 
Fraser. 

Some  experiments  seem  to  show  that  in  animals,  after  a 
resection,  the  upper  segment  of  the  intestine  remains  paretic 
after  the  lower  one  has  regained  its  power,  and  that  the  last 
part  of  all  to  become  normal  is  that  in  the  immediate  neigh- 
bourhood of  the  resection.  It  is  possible  to  start  a  peristaltic 
wave  in  the  lower  segment  some  time  before  it  can  be  originated 
in  the  upper,  and  even  when  a  contraction  can  be  brought  about 
in  the  upper  segment,  it  fails  to  move,  remaining  as  a  stationary 
constriction  of  the  gut. 


CHAPTER  III. 

WHERE  TO  OPERATE. 

The  Time  Factor. 

TABLE  VI.  was  compiled  by  dividing  the  time  between  the 
receipt  of  the  wound  and  the  performance  of  the  operation  into 
two-hourly  periods,  and  noting  whether  cases  were  sent  to  the 
Base  or  succumbed  to  their  injuries.  It  mainly  shows  two 
things  :  (1)  it  gives  some  idea  of  the  time  in  which  cases  are  got 
out  of  the  trenches  and  submitted  to  operation  ;  and  (2)  it 
shows  the  effect  on  the  mortality  of  the  time  which  has  elapsed 
between  the  receipt  of  the  injury  and  the  performance  of  the 
operation.  It  will  be  seen  that  most  cases  arrive  some  time 
between  six  and  ten  hours  after  the  receipt  of  the  injury.  Up 
to  six  hours  the  chances  are  in  favour  of  the  patient ;  after  this 
period  they  are  always  against  him. 

To  the  table  have  been  added  a  few  cases  in  which  patients 
have  died  after  an  unexpectedly  short  period,  and  also  a  few  of 
those  in  which  recovery  has  followed  the  lapse  of  a  long  period 
between  the  receipt  of  the  wound  and  the  operation.  So  far 
the  limit  in  successful  cases  has  been  forty-eight  hours  for  a 
resection  of  the  small  intestine,  and  thirty-six  hours  for  a  suture 
of  the  colon,  and  for  a  suture  of  the  stomach. 

TABLE  VI.- — 591  Cases  showing  the  Effect  of  Time  on  Mortality. 


Hours. 

2. 

4. 

6. 

8. 

10. 

12. 

14. 

16. 

18. 

20. 

22. 

0 
4 

24  and  over. 

To  Base    .  . 
Died 

3 

•_' 

30 
30 

75 
53 

55 

59 

34 
41 

19 
23 

7 
10 

4 
12 

11 
15 

4 
11 

27 
52 

Total     .  . 

5 

60 

128 

114 

75 

42 

17 

16 

26 

15 

4 

79 

War  Surgery  of  the  Abdomen 


To  Base. 

Died. 

Hours. 

Injury. 

Hours. 

Injury  or  Cause  of  Death. 

24 

Colon     

6 

Small  gut  and  haemorrhage. 

57 

Bladder      

6 

24 

Sigmoid      

5 

Gas  gangrene  of  abdominal 

30 
48 
26 

No  visceral  injury    .     .     . 

9»                                »»                   •            •            < 

Jejunum    

3 
4 
4 

wall. 
Small  gut  and  peritonitis. 
Stomach  and  duodenum. 
Small  gut  and  haemorrhage. 

15 

Stomach    

4 

Stomach. 

65 

72 

Rectum,  extrapcritoneal  . 
Colon  fistula  

3 

Multiple    wounds  of    small 
gut. 
Colon. 

4 

Spleen,     excision     of.     for 
haemorrhage. 

Where  to  operate  on  Abdominal  Cases. 

The  time  factor  table  shows  that  the  sooner  a  man  is  operated 
on  the  better.  But  there  is  another  important  factor.  The 
wounded  man  must  be  kept  quiet  and  well  nursed. 

In  certain  sectors  of  the  line  it  would  be  physically  possible 
to  operate  on  hifti  at  the  Regimental  Aid -Post  or  Advanced 
Dressing  Station,  but  it  would  be  under  the  most  disadvan- 
tageous circumstances.  After  operation  nursing,  as  usually 
understood,  would  be  impossible.  In  addition  the  man  would 
be  under  constant  shell-fire  or  close  to  our  own  guns,  both  of 
which  would  have  a  very  bad  effect  on  him.  Again,  there  are 
not  enough  surgeons  to  staff  such  places. 

It  is  therefore  necessary  to  operate  on  him  at  a  special 
operating  centre  placed  between  the  Advanced  Dressing  Station 
and  Casualty  Clearing  Station  or  to  take  him  back  to  a  Casualty 
Clearing  Station. 

In  deciding  this  it  must  be  remembered  that  the  time  occupied 
in  passing  from  the  Advanced  Dressing  Station  to  the  Casualty 
Clearing  Station  is  usually  a  very  small  part  of  the  time  that 
elapses  between  the  receipt  of  the  wound  and  the  time  of 
arrival  at  the  Casualty  Clearing  Station. 

If  therefore  the  Casualty  Clearing  Station  is  reasonably  far 


Where  to  Operate  47 

forward  (10,000 — 15,000  yards  from  the  line),  it  is,  except   in 
some  special  cases,  the  best  place  for  the  operation. 

It  may  be  well  to  say  here  something  about  the  mobile  operat- 
ing vans.  They  have  loomed  somewhat  largely  in  the  public 
mind  and  have  been  a  good  deal  discussed.  The  idea  is  that 
you  can  have  the  motor  van  fitted  out  as  an  operating-room, 
and  that  such  a  van  should  seek  the  patient  rather  than  that 
the  patient  should  be  brought  to  the  theatre.  It  may  be  stated 
at  once  that  this  idea  is  impracticable,  and  much  more  time 
would  be  spent  in  getting  to  the  patient  than  is  now  spent  in 
getting  the  patient  to  an  ordinary  Clearing  Station.  When 
speaking  of  a  mobile  hospital  van  it  must  be  understood  that 
one  does  not  include  in  this  category  a  theatre  which  can  be 
rapidly  erected,  adequately  warmed  and  lighted,  such  as  the 
French  and  Italians  use  on  many  occasions  ;  such  units  are 
only  meant  to  be  mobile  in  much  the  same  degree  as  the  Casualty 
Clearing  Station  was  intended  to  be  mobile. 

On  the  other  hand,  special  hospitals  are  very  good  when 
Casualty  Clearing  Stations  cannot  be  got  near  the  line.  I  will 
briefly  describe  some. 

The  first  one  was  situated  in  a  bleaching  mill  ;  it  was  about 
5,000  yards  behind  the  firing  line,  and  took  all  the  abdominal 
wounded  of  a  certain  corps.  It  was  formed  by  sending  an 
operating  surgeon  and  an  anaesthetist  and  four  nursing  sisters 
to  supplement  the  personnel  of  a  Field  Ambulance  which  was 
situated  in  this  building.  It  had  a  very  good  theatre  and  a 
large  ward,  which  in  cold  weather  was  steam-heated.  Here 
cases  frequently  arrived  within  two  hours  or  less,  the  patients 
being  carried  straight  from  the  spot  where  they  were  wounded 
to  the  hospital,  irrespective  of  what  Division  they  belonged  to 
This  hospital  was  never  pressed  and  never  had  the  strain  of  a 
large  fight  placed  upon  it.  It  continued  to  do  its  good  work 
until  the  enemy  began  to  pay  attention  to  a  bridge  which 
crossed  a  canal  on  whose  banks  the  mill  was  situated.  Then 
it  was  shifted  a  bit  to  one  side  and  to  another  building  which 
was  much  less  commodious.  There  it  remained  until  the  area 
passed  out  of  the  jurisdiction  of  the  Army.  The  sisters  and 
operating  surgeon  and  anaesthetist  were  then  moved  to  a 


48  War  Surgery  of  the  Abdomen 

different  part  of  the  line,  and  were  re-established  in  the  ugliest 
chateau  it  has  been  my  misfortune  to  see.  It  was  situated 
about  9,000  yards  behind  the  line  and  in  a  very  much  more 
difficult  sector  as  far  as  evacuation  was  concerned.  Here  it 
continued  to  do  excellent  work,  although  the  railhead  and  a 
coal-mine  near  by  were  continually  shelled,  many  of  the  shells 
coming  into  the  garden  uncomfortably  close  to  the  house.  It 
was  closed  at  last,  as  a  Casualty  Clearing  Station  was  opened 
near  by.  This  hospital  was  also  never  pressed ;  and  the  results, 
as  in  the  last,  were  very  good. 

The  third  hospital  was  opened  in  a  Field  Ambulance  just 
before  the  onset  of  a  big  battle  ;  and  it  was  arranged  that  all 
the  abdominal  wounded  from  a  Corps  should  be  brought  to  it. 
As  a  matter  of  fact,  in  the  stress  of  battle  the  wounded  from 
two  Corps  were  carried  to  it.  The  result  was  that  the  place 
was  heavily  worked,  and  the  results  were  not  so  good  as  in  the 
last  two. 

A  fourth  abdominal  hospital  may  be  mentioned,  because 
there  are  some  lessons  which  can  be  learnt  from  it.  Experience 
had  been  gained  by  the  overwork  of  the  last  hospital,  and 
adequate  arrangements  were  made  to  prevent  it.  The  personnel 
of  this  particular  hospital  was  adequate  for  its  needs.  In 
addition  it  was  arranged  that  when  the  hospital  became  full 
the  wounded  should  be  sent  on  to  a  Casualty  Clearing  Station 
situated  somewhere  farther  back.  The  result  of  this  arrange- 
ment was  that  all  the  abdominals  that  had  the  good  fortune  to 
be  admitted  were  well  and  rapidly  treated. 

The  lesson  to  be  learnt  from  the  experience  gained  at  such 
hospitals  can  be  summarised  as  follows  :  that  in  quiet 
times  such  hospitals  opened  at  Field  Ambulances  by  the 
provision  of  an  operating  surgeon  and  a  few  sisters  can  do 
magnificent  work  and  save  life.  If,  on  the  other,  hand,  such 
hospitals  are  to  be  opened  in  times  of  battle,  it  is  necessary  to. 
have  very  much  the  same  personnel  that  is  allowed  to  a  Casualty 
Clearing  Station.  Unless  a  large  number  of  beds  are  provided, 
the  hospital  soon  becomes  full,  and  the  personnel  is  not  used  to 
its  full  capacity* 

On  the  whole  the  better  plan  is  to  evacuate  all  the  abdominals 


49 

to  the  front  line  Casualty  Clearing  Stations,  while  allowing  the 
less  seriously  wounded  to  pass  to  those  in  the  rear.  Care  must 
be  taken  to  make  the  personnel  of  the  hospital  receiving 
abdominal  cases  adequate  for  its  work  ;  otherwise  some  cases 
will  only  be  admitted  to  wait  longer  than  if  they  had  been 
sent  farther  back.  Taking  all  cases  that  enter  a  Casualty 
Clearing  Station,  it  is  not  possible  to  put  many  more  than 
twenty-five  such  cases  on  an  operation  table  in  twenty-four  hours. 
If  the  proportion  of  abdominal  cases-  admitted  is  high  the 
number  of  cases  that  can  be  operated  on  is  very  much  lower. 

Arrangements  at  the  Present  Time  in  the  French  and  Belgian  Armies. 

It  has  been  said  above  that  the  French  and  Belgians  went 
through  the  same  experience  as  ourselves.    Since  the  line  became 
fixed  operation  has  been  the  accepted  practice.      The  French 
have  established    advance    abdominal  hospitals  by  means  of 
what  they  call  motor  surgical  ambulances  ;    these  are  really 
hutted   theatres   which   can  hfe   easily   erected,   and  they  are 
extremely  complete  in  their  arrangements.     These  hospitals, 
which  correspond  with  our  Advanced  Operating  Centres,  are 
pushed  rather  farther  forward  than  is  the  practice  in  the  British 
Army,  and  have,  I  believe,  met  with  a  large  measure  of  success. 
Professor  Turner  also  informs  me  that  the  French  have  tried 
the  experiment  of  "dug-out"  operating  centres  situated  some 
hundreds  of  metres  behind  the  trenches,  where  it  is  possible  to 
operate  on  the  wounded  in  from  a  half  to  two  hours  after  the 
accident.      He  adds — which  is  of  considerable  interest — that, 
with  the  very  large  attacks  they  have  had  and  the  great  number 
of  wounded  they  have  had  to  be  dealt  with,  this  arrangement 
has  not  given  very  good  results,  for  the  reason  that  the  wounded 
have  arrived  late,  and  very  often  these  ambulances  have  been 
unable  to  deal  with  the  numbers  of  wounded  they  have  received. 
The  Belgians  have  followed  suit  to  a  certain  degree,  and  have 
pushed  their  abdominal  operating  centres  far  forward,  and  have 
lately  provided  special  ambulances  for  the  transmission  of  the 
operated  man  to  the  hospitals  farther  back.    I  have  not  so  far 
ascertained  what  measure  of  success  they  have  had,  but  the 
Belgians  are  favourably  situated  in  that  they  have  large  base 

W.S.A.  4 


5o  War  Surgery  of  the  Abdomen 

hospitals  very  close  behind  the  firing  line.  They  have,  toe,  had 
no  large  offensives.  The  Italians  have  used  mobile  operating 
ambulances  in  the  same  manner  as  the  French.  In  the  moun- 
tains where  the  fighting  has  taken  place  evacuation  is  extremely 
difficult ;  and  such  centres  have,  therefore,  proved  exceedingly 
useful. 


CHAPTER   IV. 

DIAGNOSIS  AND  TREATMENT  CONSIDERED  GENERALLY. 

» 

Diagnosis  of  Intraperitoneal  Damage. 

THIS  is  determined  in  three  ways  :  (1)  by  inspection  ;  (2)  by 
experience  ;  (3)  by  symptoms. 

With  all  possible  care,  and  an  extensive  experience,  and  a  full 
appreciation  of  the  numerous  fallacies,  it  is  frequently  difficult 
to  make  sure  that  the  wound  is  penetrating.  If  it  is  difficult 
when  there  is  an  entrance  and  exit  wound,  it  is  still  more  so  when 
there  is  only  one  wound.  It  may  be  that  shock,  haemorrhage, 
rigidity,  or  rapid  pulse  will  be  present ;  in  some  cases  which  are 
received  early,  there  maybe  no  such  guides.  It  may  be  said  that 
the  wound  of  a  hollow  viscus  has  in  itself  no  symptoms  ;  it  is 
haemorrhage  or  peritonitis  which  give  the  danger  signal. 

(1)  BY  INSPECTION. — Antero-posterior  wounds  are  the  easiest 
to  judge.  The  only  point  to  be  remembered  is  the  thickness  of 
the  flank  muscles.  Below  the  transpyloric  plane  a  wound  with 
the  entrance  on  one  side  of  the  middle  line,  and  an  exit  near  the 
lateral  body  line  of  the  same  side,  is  very  often  non-penetrating, 
or  has  just  opened  the  peritoneum.  Above  the  transpyloric 
line  such  a  wound,  owing  to  the  rounded  form  of  the  thorax, 
is  almost  certain  to  be  penetrating.  The  bullet  which  passes  in 
and  out  between  the  semilunar  lines  probably  does  not  open  the 
abdomen,  while  the  one  that  passes  in  and  out  outside  these 
lines  probably  does.  In  the  longitudinal  direction,  a  bullet 
which  enters  near  the  costal  margin,  and  emerges  above  the 
groin,  will  most  likely  traverse  the  abdomen.  Where  it  is  a 
question  of  single  wounds,  there  is  really  no  guide  except  the 
symptoms,  as  it  is  usually  impossible  to  tell  the  direction  of  the 
projectile.  Much  help  is  afforded  by  an  X-ray  examination  in 
such  cases.  One  case  may  be  quoted  as  showing  the  difficulty  of 
judging  where  a  missile  has  gone — a  man  was  shot  beside  the 
umbilicus.  The  shape  of  the  wound  suggested  a  bullet.  The 

4—2 


52  War  Surgery  of  the  Abdomen 

area  was  a  dangerous  one,  so  it  was  determined  to  explore  the 
abdomen.  As  the  wound  was  in  a  convenient  situation,  the 
exploratory  incision  was  made  through  it.  It  was  then  found 
that  the  rectus  muscle  was  torn  the  length  of  the  incision.  This 
was  enlarged  downwards  to  the  pubes,  the  muscle  being  much 
torn  down  to  the  bone,  but  the  sheath  and  peritoneum  were 
intact.  The  bullet  had  passed  down  behind  the  pubes'.  As 
there  were  no  symptoms,  nothing  further  was  done,  and  the 
case,  after  an  interval  of  several  days,  was  sent  to  the  Base 
doing  well. 

The  possibility  of  rupture  of  underlying  organs  in  such  cases 
must  be  carried  in  mind,  and  it  is  well  to  err  on  the  side  of 
opening  the  abdomen. 

(2)  BY  EXPERIENCE. — This  has  shown  that  one  has  to  be  very 
careful  in  making  a  negative  diagnosis,  and  it  has  also  shown 
the  wisdom  of  operation  in  doubtful  cases. 

Bomb  wounds  require  some  notice  under  this  heading.  The 
fragments  into  which  a  bomb  is  broken  on  explosion  are  often 
very  small,  but  so  high  is  their  velocity  that  they  have  very 
great  power  of  penetration.  The  wounds  may  be  so  small 
and  insignificant  that  it  sometimes  takes  real  strength  of  mind  to 
explore  the  abdomen,  although  the  symptoms  point  to  the 
possibility  of  visceral  involvement.  The  number  of  these 
wounds  makes  individual  exploration  impossible,  and  the  only 
way  of  settling  the  matter  is  to  explore  the  abdomen  by  a  well- 
placed  incision,  irrespective  of  the  situation  of  the  wounds. 

(3)  BY  SYMPTOMS. — These  may  be  enumerated  as  follows  : 
appearance  ;   pulse  ;   vomiting  ;   haemorrhage  ;   rigidity  ;   pain  ; 
tenderness  ;   subjective  sensations  ;   shock. 

Appearance. — Usually  a  man  hit  in  the  abdomen  looks  ill. 
Sometimes  he  appears  to  have  no  serious  lesion.  Often  he  is 
shocked  and  cold,  in  spite  of  blankets  and  hot  bottles,  with  which 
he  has  been  surrounded  in  the  ambulance.  Sometimes  he  is 
apathetic  and  quiet,  sometimes  restless,  sometimes  from  pain, 
sometimes  from  distress.  He  may  be  blanched  or  of  a  fair  colour, 
even  normal  in  appearance.  Before  rapid  evacuation  was  the  rule 
one  was  struck  by  the  fallaciously  good  facial  expression  of  some 
of  these  cases,  and  often  experienced  a  shock,  on  taking  up  a 


Diagnosis  and  Treatment  Considered  Generally   53 


man's  hand,  to  find  it  cold  and  clammy,  and  the  pulse  running 
or  even  not  palpable.  Such  cases  invariably  die,  and  operation 
only  hastens  their  end. 

Pulse. — A  rapid  pulse,  a  pulse  that  does  not  fall,  or  a  rising 
pulse,  is  an  indication  for  operation.  A  slow  pulse  is  not  neces- 
sarily a  contra-indication  unless  the  wound  is  in  a  non-dangerous 
area  such  as  the  liver..  I  have  seen  a  man  with  a  pulse  of  60 
with  four  holes  in  his  small  intestine  four  hqurs  after  receipt  of 
the  injury.  A  rapid  pulse  is  caused  by  loss  of  blood,  and  later 
on  by  peritonitis  and  sepsis.  It  does  not  seem  to  have  any  very 
definite  connection  with  the  number  of  lesions  of  the  intestine. 
The  pulse  often  falls  with  rest  and  quiet.  Often  a  falling  pulse 
is  more  an  indication  of  the  possibility  of  operation  than  a 
contra-indication  to  operative  measures. 

From  Table  VII.  one  can  see  the  general  average  pulse  of  a 
man  wounded  in  the  abdomen.  A  pulse  of  100  is  very  common, 
and,  on  the  whole,  gives  a  good  prognosis.  A  pulse  of  120  seems 
to  be  a  critical  one,  for  the  mortality  is  here  rapidly  mounting. 
Of  145  patients  with  a  pulse  over  120  only  16  recovered. 


TABLE  VII.— To   show   Effect   on   Pulse   of  Prognosis. 

Xumber,  577. 


Total 


1'nlsc  up  to  and 
including 

60. 

70. 

80. 

90. 

100. 

110. 

120. 

130. 

140 
and  over. 

To  Base      .  . 

1 

7 

23 

30 

108 

27 

37 

7 

9 

Died 

1 

2 

13 

18 

39 

38 

88 

37 

92 

Total       .  . 

2 

9 

36 

48 

1  17 

65 

12.5 

44 

101 

Mention  may  be  made  here  of  unexpected  results  which  some 
pulse-rates  show.  A  man  having  a  pulse  of  160  with  a  wound  in 
the  liver  went  to  the  Base  without  operation.  A  pulseless  man 
recovered  after  his  bladder  and  small  intestine  had  been  sutured. 
A  mail  with  a  pulse  of  60  died  from  the  effects  of  haemorrhage 
although  the  bleeding  was  stopped  by  operation.  A  man  with  a 
pulse  of  90  died  of  gas  gangrene  in  the  abdominal  wall.  Another 


54  War  Surgery  of  the  Abdomen 

with  a  pulse  of  80  died  of  peritonitis  on  the  third  day.  One  case 
with  a  pulse  of  160  recovered,  the  reason  for  the  rapidity  being 
an  extraperitoneal  haematoma  of  the  bladder,  which  was 
drained. 

Vomiting. — Wounds  of  the  stomach  nearly  always  lead  to 
vomiting,  and  very  often  to  haematemesis  ;  but  vomiting  is  also 
met  with  in  all  kinds  of  wounds  other  than  abdominal ;  and, 
beyond  the  fact  that  its  absence  shows  that  the  stomach  is  most 
probably  not  involved,  it  has  no  special  significance  or  indication. 

Haemorrhage. — This  will  be  dealt  with  more  fully  later  on 
(p.  130).  It  is  sufficient  to  say  here  that,  with  the  exception  of 
blanching  and  a  rapid  pulse,  both  of  which  may  be  produced  by 
other  causes,  the  classical  signs,  such  as  restlessness,  blindness, 
or  air  hunger,  are  usually  absent.  Haemorrhage  gives  the 
ordinary  physical  signs  ;  but,  as  is  well  known,  these  are  not 
very  helpful,  for  to  produce  them  the  amount  of  blood  may 
have  to  be  very  great. 

Rigidity. — This  is  a  very  constant,  but  varying  symptom. 
It  is  seen  (a)  in  low  thoracic  injuries  ;  (b)  in  wounds  of  the 
abdominal  wall,  pelvic  floor,  and  even  of  the  thigh ;  and 
(c)  with  visceral  injuries. 

(a)  The  rigidity  produced  in  the  abdomen  by  low  thoracic 
injuries  is  well  known,  and  it  renders  diagnosis  very  difficult, 
especially  in  cases  where,  from  a  study  of  the  track,  the  bullet 
may  or  may  not  have  entered  the  abdomen.  One  such  case  I 
well  remember,  in  which  a  man,  hit  in  the  lower  right  axillary 
region,  presented  a  universal  rigidity  of  the  abdominal  wall, 
accompanied  by  considerable  pain.  His  condition  otherwise 
was  not  bad.  It  was  determined  to  watch  him,  and  he  was  put 
to  bed  and  kept  quiet  for  three  hours.  At  the  end  of  that  time 
the  rigidity  had  become  board-like.  There  was  considerable 
increase  in  his  pain,  and  his  pulse-rate  was  slightly  accelerated. 
An  abdominal  exploration  showed  that,  after  all,  the  abdomen 
was  uninvolved,  and  that  the  only  possible  injury  was  a  wound 
of  the  liver  on  its  extraperitoneal  surface.  Curiously  enough, 
this  man  died  of  tetanus  a  week  later.  A  piece  of  shell  loose  in 
the  pleural  cavity  will  also  harden  the  abdominal  muscles. 

I  do  not  know  that  there  is  any  royal  road  to  diagnosis 


Diagnosis  and  Treatment  Considered  Generally   55 

between  a  thoracic  and  abdominal  wound.  It  is  often  noticed 
that,  if  a  man  is  placed  in  a  semi-recumbent  position,  the 
abdominal  rigidity  tends  to  abate  if  the  injury  is  only  thoracic. 
Captain  B.  C.  Maybury  has  an  idea  that  superficial  abdominal 
tenderness  is  rather  a  feature  of  thoracic  wounds. 

(b)  In  the  wounds  of  the  abdominal  wall  the  rigidity  is  apt  to 
be  local,  and,  as  a  rule,  does  not  give  rise  to  very  much  con- 
fusion.    Contusions  of  the  abdomen  do  present  considerable 
difficulty,  and  in  cases  which  recover  without  operation  marked 
rigidity,  an  extremely  rapid  pulse,  and  pallor  may  all  be  com- 
bined.   Wounds  of  the  pelvic  floor,  even  when  not  penetrating, 
will  produce  a  reflex  hardness  of  the  anterior  wall,  as  may 
wounds  of  the  upper  thigh. 

(c)  Injuries  both  of  the  solid  and  hollow  viscera  are  accom- 
panied by  rigidity.    This  rigidity  seems  to  be  brought  about  in 
two  ways  :   (1)  it  is  a  reflex  protective  measure  after  the  receipt 
of  any  wound  ;   (2)  it  is  also  brought  about  by  irritation  of  the 
peritoneum,  either  by  blood  or  infection.     It  is  largely  inde- 
pendent of  the  amount  of  peritoneal  infection,  and  occurs  in  an 
extreme  form  without  any  naked-eye  appearance  of  inflamma- 
tion.   Under  such  conditions  it  is  generally  accompanied  by  very 
great  pain. 

Rigidity  often  occurs  when  there  is  blood  in  the  abdomen  the 
source  of  which  is  only  a  wound  of  the  mesentery  or  omentum. 
It  is  not,  as  a  rule,  very  marked  in  these  cases,  and  tends  to  sub- 
side with  time,  in  contradistinction  to  that  due  to  peritonitis, 
which  is  progressive.  One  occasionally  sees  a  somewhat  rigid 
and  tumid  condition  of  the  abdomen  in  cases  arriving  late  ; 
such  a  condition  is  usually  only  a  sign  of  haemorrhage  which 
has  been  arrested  ;  such  cases  are  usually  best  left  unoperated. 

Considered  clinically,  (1)  rigidity  may  be  slight,  and  this 
generally  or  locally.  (2)  It  may  be  confined  to  one  part,  and  if 
this  spreads  it  generally  means  an  intestinal  lesion.  (3)  Alter- 
nating rigidity.  During  examination  the  abdomen  is  sometimes 
soft  and  sometimes  hard.  This  is  a  very  puzzling  condition,  and 
its  indication  is  not  very  clear  ;  it  is  sometimes  accompanied  by 
extensive  injuries.  (4)  Apprehensive  rigidity,  if  one  may  use 
the  term.  Here,  although  the  abdomen  looks  soft  and  moves  on 


56  War  Surgery  of  the  Abdomen 

respiration,  it  at  once  hardens  when  the  hand  approaches  to 
palpate.  As  a  rule  it  is  accompanied  by  no  serious  injury. 
(5)  Board-like  rigidity  is  most  puzzling  when  accompanied  by  a 
slow  pulse.  If  there  is  extreme  pain,  it  nearly  always  means 
that  there  is  a  wound  of  the  intestine.  (6)  Complete  absence  of 
rigidity  ;  this,  when  accompanied  with  obvious  penetration  of 
the  abdomen,  is  often,  as  has  been  pointed  out  by  Taylor  and 
Meyer,  a  very  bad  sign.  One  case  of  such  a  condition  may  be 
quoted  :  A  man  was  hit  in  several  places  on  the  abdominal 
wall  by  small  fragments  of  an  aerial  bomb  within  a  few  yards 
of  an  Advanced  Operating  Centre.  He  was  admitted  within  a 
few  minutes  of  the  injury.  He  was  shocked,  but  not  cold.  His 
pulse  was  130  and  very  poor.  His  abdomen  was  perfectly  lax, 
and  continued  so  till  death,  about  twelve  hours  later.  He 
complained  of  much  epigastric  pain.  Three  hours  after  wounding 
his  condition  seemed  hopeless,  as  his  pulse  was  small  and  feeble 
(130),  and  his  extremities  blue  and  cold  in  spite  of  artificial 
warmth.  Notwithstanding  his  bad  condition,  he  lingered  on 
for  many  hours.  A  post-mortem  showed  that  he  had  three  small 
holes  in  the  jejunum  and  about  two  pints  of  blood  in  the  belly 
cavity.  This  case  shows  the  difficulty  in  determining  whether 
to  operate  or  not.  Had  he  been  transfused,  he  might  have  stood 
an  operation.  A  lax  abdomen  may  exist  with  hollow  viscera 
lesions  and  the  patient  be  in  good  state. 

It  may  be  here  stated  that  morphia  in  moderate  doses  seems 
to  have  very  little  effect  on  the  state  of  the  abdominal  wall. 

The  Spinal  Abdomen. — One  has  to  be  on  one's  guard  not  to  be 
misled  by  the  slightly  rigid  and  tumid  abdomen  which  is  met 
with  in  cases  of  spinal  injury,  and  especially  when  such  injuries 
are  accompanied  by  vomiting.  This  state  of  the  abdomen  is 
sometimes  caused  by  a  distended  bladder,  but  it  may  be  present 
without  it. 

Tenderness. — This  has  very  much  the  same  value  as  the 
tenderness  met  with  in  penetration  of  the  intestine  due  to 
disease.  The  point  of  maximum  tenderness  may  coincide  with 
the  position  of  the  gut  lesion. 

Pain. — Is  nearly  always  present  in  some  form  or  another  ;  it 
varies  from  almost  uncontrollable  agony  to  nothing  more  than 


Diagnosis  and  Treatment  Considered  Generally   57 

discomfort.  It  usually  comes  on  at  once.  There  does  not  seem 
to  be  any  particular  relation  between  the  amount  of  pain  and  the 
amount  of  injury. 

Subjective  Sensations  and  Shock. — Are  dealt  with  later  (p.  135). 

Care  of  the  Patient  before  Operation. 

IN  TRANSIT  TO  HOSPITAL. — Captain  Moore  has  pointed  out 
that  a  man  wounded  in  the  abdomen  is  more  comfortable  if  he 
can  be  put  in  such  a  position  that  his  abdominal  muscles  are 
relaxed.  The  patient  should  be  covered  up  as  soon  as  possible 
and  kept  warm  by  adequate  blankets  and  hot  water  bottles  or 
hot  bricks  (see  "  Treatment  of  Shock,"  p.  138). 

Morphia. — The  subcutaneous  method  of  administration  is 
the  best.  The  buccal  method  is  not  reliable.  If  the  tabloid 
is  dissolved  in  the  mouth  and  absorbed  by  the  mucous  mem- 
brane, it  acts  quickly.  There  is,  however,  the  risk  that  the 
tabloid  is  swallowed  and  action  thereby  delayed.  It  thus 
happens  that  a  further  subcutaneous  dose  is  given  to  allay  the 
continuing  pain.  After  a  time  the  swallowed  morphia  begins 
to  act  and  produces  its  own  effect  in  addition  to  that  of  the 
dose  given  under  the  skin. 

Soldiers  have  in  addition  carried  morphia,  with  which  they 
have  dosed  themselves,  unknown  to  the  medical  officer.  Morphia 
used  beyond  the  point  of  relieving  pain  is,  in  my  opinion, 
prejudicial  to  the  patient. 

Initial  ^-grain  doses  are  to  be  avoided ;  a  |  or  ^-grain  dose  is 
nearly  always  sufficient. 

It  is  very  important  that  the  amount,  the  method  of  adminis- 
tration, and  the  time  be  all  entered  in  the  patient's  tally. 

Morphia  should  be  given  as  soon  as  possible  after  receipt  of 
the  wound.  It  allays  the  apprehension  that  men  feel  when 
lifted  high  on  a  stretcher,  possibly  above  the  edge  of  the 
trench. 

The  Withholding  of  Fluids. — There  is  no  reason  why  fluid 
should  not  be  given  in  reasonable  amounts  ;  its  withholding 
causes  great  distress  to  the  patient,  who  is  very  likely  suffering 
already  from  a  lack  of  fluid  in  his  body.  Bicarbonate  of  soda 
can  with  advantage  be  given  at  this  stage. 


58  War  Surgery  of  the  Abdomen 

IN  HOSPITAL. — When  a  patient  arrives  at  an  operating 
hospital,  the  question  of  immediate  operation  has  to  be  con- 
sidered. It  is  better  to  put  the  man  to  bed  and  watch  his  condi- 
tion for  a  little  than  to  immediately  subject  him  to  operation. 
It  is  quite  true  that  haemorrhage  is  the  great  danger,  but  still 
experience  has  led  me  to  think  that  on  the  whole  a  little  rest 
does  more  good  than  harm.  The  interval  is  used  to  improve  the 
man's  condition. 

First  and  foremost  as  a  remedial  measure  is  the  warming  of 
the  patient.  This  is  by  far  the  best  treatment  of  shock,  and 
greatly  transcends  in  importance' the  administration  of  stimu- 
lants, of  whatever  nature,  either  by  the  mouth  or  hypoder- 
mically.  It  is  very  remarkable  to  what  an  extent  the  treatment 
by  drugs  has  fallen  in  favour. 

It  is  often  wise  to  warm  the  patient  up  on  the  stretcher  on 
which  he  arrived  by  placing  a  lamp  beneath  it  and  forming  a 
hot  chamber  by  hanging  blankets  over  the  sides  and  ends.  If 
it  should  be  decided  to  undress  him,  this  should  be  done  on 
such  a  stretcher.  When  undressed  he  can  be  placed  in  bed  and 
heated  by  the  electric  or  hot  air  cradle.  If  heat,  rest,  and 
morphia  do  not  improve  a  man's  condition,  it  is  doubtful  if 
transfusion  or  infusion  will  produce  any  effect. 

Fluid  can  be  introduced  into  the  system  by  the  mouth,  by  the 
rectum,  subcutaneously,  or  intravenously  ;  it  depends  upon  the 
state  of  the  patient  and  his  capabilities  of  reception.  If  the 
patient  cannot  drink  the  intravenous  method  is  by  far  the  best 
and  surest.  The  fashionable  method  of  subcutaneous  saline  is 
practically  valueless  in  a  shocked  man.  If  the  patient  can 
drink,  it  is  well  to  increase  his  alkaline  reserve  by  giving  a 
drachm  of  bicarbonate  of  soda  in  water  and  follow  it  up  with 
sweetened  tea  or  coffee.  If  unable  to  retain  fluids  by  the  mouth, 
an  infusion  of  bicarbonate  of  soda,  2 — 4  per  cent.,  is  recom- 
mended, unless  there  has  been  much  bleeding.  If  haemorrhage 
is  feared,  transfusion  of  blood  is  by  far  the  best  restorative. 
Many  believe  that  transfusion  is  best  given  during  or  at  the 
end  of  the  operation.  If  blood  is  given  before  operation,  the 
opening  of  the  abdomen  should  not  be  delayed  for  long.  The 
same  applies  to  all  intravenous  injections  on  account  of  their 


Diagnosis  and  Treatment  Considered  Generally    59 

tendency  to  retard  haemorrhage.  The  transfusion  may  be 
followed  by  an  infusion  of  bicarbonate  of  soda  (2 — 4  per  cent.). 
If  blood  is  not  available,  an  infusion  of  6  per  cent,  gum  acacia 
in  a  2  per  cent,  bicarbonate  solution  is  a  good  substitute. 

The  actual  moment  for  performing  the  operation  must  be  left 
to  the  individual  judgment  of  the  operator.  If  the  man  does 
not  respond  at  all,  the  question  must  be  decided  whether  it  is 
best  to  operate  at  once  or  whether  it  is  worth  operating  at  all. 
The  pulse  (see  Table  VIII.)  will  give  some  help.  Frequently 
even  as  much  as  six  or  eight  hours'  rest  will  produce  such 
improvement  that  an  operation  is  possible  where  at  first  the 
case  seemed  hopeless. 

Operation. — The  operation  table  must  be  adequately  warmed, 
and  the  length  of  the  operation  curtailed,  not  by  undue  haste, 
but  by  careful  preparation.  Whatever  anaesthetic  is  used, 
cyanosis  must  be  avoided. 

Question  of  Operation. 

Experience  has  shown  the  wisdom  of  operating  as  a  routine 
measure,  and  it  is  now  mainly  a  question  of  excluding  the  case* 
on  which  it  is  best  not  to  operate. 

It  can  be  admitted  that  this  line  of  treatment  involves 
operating  on  some  patients  who  have  no  visceral  injury  and  on 
some  in  whom  the  wounded  parenchyma  of  solid  organs  has 
ceased  to  bleed. 

On  the  whole  "Look  and  see  "  is  a  better  maxim  than  "Wait 
and  see." 

It  may  be  useful  to  enumerate  those  cases  which  are  best 
left  alone. 

(1)  Cases  in  very  Bad  Condition.- — There  are,  of  course,  many 
cases  which  no  surgeon  would  feel  himself  justified  in  operating 
on  ;   but  there  are  many  border-line  cases,  which  some  surgeons 
would  leave,  and  others  would  feel  constrained  to  submit  to 
operation.     Here  the  personal  equation  comes  in,  and  whether 
he  operates  or  not  must  be  left  to  the  surgeon  to  decide.    The 
pulse  will  be  a  valuable  guide.    The  bolder  surgeon  may  get  the 
worse  operative  mortality  and  yet  save  more  lives. 

(2)  Cases  shot  high  up  in  the  Abdomen  in  the  Liver  Area. — Such 


60  War  Surgery  of  the  Abdomen 

cases  on  the  whole  do  very  well  if  left  alone,  so  long  as  there  are 
no  symptoms  of  haemorrhage ;  in  fact,  haemorrhage  and  the 
retention  of  a  large  missile  are  the  only  reasons  for  operating  on 
liver  cases. 

(3)  High  Abdomino-thoracic   Wounds  on  the  Left  Side. — The 
type  of  wound  more  especially  referred  to  is  that  which  enters 
near   the   mid-line   behind,   and   emerges    somewhere   towards 
the  posterior  part  of  the  axilla  about  the  level  of  the  sixth  to 
the  eighth   rib.      These   wounds   are    sometimes   accompanied 
by  symptoms   suggesting  stomach    involvement,    but    on   the 
whole  do  not  seem  to  do  badly.     Operative  interference  does 
not  afford  very  much  help,  as  wounds  high  up  in  the  cardia  or 
near  the  oesophagus  may  be  almost  impossible  to  close,  or,  if 
they  can  be  reached,  involve  such  disturbances  as  are  likely 
to  lead  to  a  fatal  result.     If  operation  is  decided  upon,  the 
transpleural  route  is  the  best. 

(4)  Cases  arriving  late.— I  am  inclined  to  put  down  twenty- 
four  hours  as  a  usual  limit  within  which  a  primary  operation  is 
likely  to  be  successful ;  haemorrhage  by  this  time  has  ceased,  and 
operation  is  only  likely  to  spread  infection  if  the  bowel  has  been 
perforated,  and  to  hasten   the  end.      There  are  some  cases  in 
which  operation  may  be  thought  advisable,  namely,  those  with 
a  fair  pulse  but  with  vomiting,  the  operation  being  performed 
with  an  idea  of  getting  over  the  "  obstruction  "  by  short-cir- 
cuiting or  an  enterostomy.    Operations  of  this  class  have  nearly 
all  been  fatal. 

The  operation  of  simple  supra-pubic  drainage  is  an  absolutely 
useless  disturbance. 

Wounds  on  Back  to  be  first  Treated. 

Marshall  has  shown  that  rolling  a  patient  over,  after  coeliotomy, 
to  reach  wounds  on  the  back  of  the  body  causes  a  great  fall  in 
blood  pressure.  Such  wounds,  if  they  arc  to  be  treated,  should 
be  attended  to  before  opening  the  abdomen. 

The  Incision. 

(1)  Its  Site. — This  must  be  planned  rather  with  a  view  to  dealing 
with  the  probable  nature  of  the  injury  than  with  any  reference 


Diagnosis  and  Treatment  Considered  Generally   61 

to  the  wounds.  With  an  in-and-out  wound  we  know  the  course 
of  the  projectile,  and  can  form  a  fair  estimate  of  the  organs 
likely  to  be  involved.  With  a  single  wound  this  is  practically 
impossible,  and  here  an  X-ray  apparatus  is  invaluable,  as  it 
enables  us  to  place  the  abdominal  incision  in  the  best  possible 
situation. 

To  give  an  instance  of  the  value  of  X-rays  :  suppose  there  is 
a  single  entry  wound  near  the  semilunar  line.  Without  an 
X-ray  examination  the  only  thing  is  to  open  the  abdomen  in 
the  middle  line  and  ascertain  the  course  of  the  missile  ;  this 
involves  an  exploration  of  the  entire  abdomen,  and  in  the  end  it 
may  be  found  that  the  only  viscus  injured  is  the  colon  at  its 
peritoneal  reflexion.  The  exploratory  procedure  will  have 
exposed  the  whole  abdomen  to  the  danger  of  contamination. 
On  the  other  hand,  an  X-ray  picture  would  have  located  the 
missile  in  the  loin,  and  shown  at  once  that  a  horizontal  explora- 
tory wound  would  have  met  all  the  circumstances  of  the  case, 
and  possibly  saved  a  life. 

Vertical  Incisions. — A  paramedian  incision  is  the  standard 
method  of  opening  the  abdomen,  and  it  should  be  used  in  all 
cases  unless  there  is  some  distinct  indication  to  the  contrary. 
It  is  always  better  to  prolong  it  than  to  make  lateral  right-angle 
extensions.  The  length  should  be  about  8  inches  ;  if  in  doubt, 
it  is  better  to  use  a  longer  one,  as  free  access  means  a  great 
increase  in  celerity  and  less  manipulation  of  the  intestines 
outside  the  belly  cavity. 

In  some  antero-posterior  wounds  towards  the  lateral  line  of 
the  body,  a  rectus-sheath  incision  has  something  to  recommend 
it  :  the  colon  can  be  reached  and  the  field  of  operation  limited. 
It  is  not,  however,  a  good  incision  to  close,  and  divides  many 
nerves. 

Transverse  Incisions. — In  those  cases  where  the  missile  has 
perforated  the  body  from  near  the  mid-line  to  the  loin,  whether 
this  direction  is  shown  by  an  entrance  or  an  exit  wound  or  by 
the  aid  of  a  skiagram,  the  transverse  incision,  either  horizontal 
or  parallel  to  the  upper  or  lower  abdominal  limits,  is  much  to  be 
recommended.  If  more  room  is  required,  it  can  be  obtained  by 
cutting  the  rectus  sheath,  but  leaving  the  rectus  muscle  intact. 


62  War  Surgery  of  the  Abdomen 

Sueh  an  incision  allows  free  access  to  the  hepatic  and  splenic 
flexures  and  the  vertical  colons,  to  the  kidney,  and  to  thes  pleen. 
It  allows  removal  or  exploration  of  the  kidney  without  rolling 
the  patient  far  over — a  great  advantage,  for  Marshall  has  shown 
that  such  movement  is  followed  by  an  alarming  drop  in  the  blood 
pressure  at  the  close  of  an  abdominal  operation.  It  also  permits 
an  easy  examination  of  the  upper  small  intestine,  and  of  the 
lower  with  a  little  more  difficulty,  if  necessary.  It  is  the  only 
incision  that  allows  the  ascending  and  descending  colons  to 
be  easily  and  properly  repaired,  and,  in  addition,  is  a  con- 
venient situation  for  an  artificial  anus.  It  is  not  a  convenient 
incision  for  the  stomach,  except  for  that  portion  situated  near 
the  spleen. 

A  similar  incision  starting  behind,  and  prolonged  forward  if 
necessary,  can  be  used  with  advantage  in  exploring  postero- 
lateral  wounds  of  the  body.  A  subcostal  incision  is  also  good  in 
some  liver  wounds.  Such  incisions  suture  easily  and  heal 
kindly.  In  some  cases  of  wounds  in  the  back  of  the  loin,  it  is 
better  to  open  the  abdomen  in  the  mid-line  and  make  sure  that 
the  peritoneum  has  not  been  involved.  If  it  has,  the  wound  is 
closed  and  the  loin  opened  up,  and  the  necessary  steps  are  taken 
to  deal  with  the  condition  found.  It  is  always  very  important, 
when  there  is  a  possibility  of  a  colon  wound,  to  do  everything  to 
prevent  contamination  of  the  general  abdominal  cavity. 

(2)  Its  Closure. — The  method  of  closure  must  depend  on  the 
condition  of  the  patient.  If  this  is  critical,  it  must  be  by  through - 
and-through  sutures.  If  there  is  time,  an  attempt  should  be 
made  to  close  the  peritoneum  separately ;  many  of  these 
wounds  suppurate,  and  it  is  impossible  to  prevent  the  suppura- 
tion extending  to  the  intestines  if  the  peritoneum  is  unsutured. 
If  the  patient's  condition  allows,  the  wound  can  be  closed  in 
layers,  but  in  every  case  there  should  be  at  least  three  through - 
and-through  supporting  stitches  which  only  miss  the  peri- 
toneum. 

Suppuration  in  the  operation  wounds  has  been  a  trouble.  It 
may  be  partly  due  to  defective  technique  ;  but  in  many  cases 
one  has  to  remember  that  the  blood  in  the  abdomen,  which  must 
well  out  when  the  cavity  is  opened,  is  full  of  micro-organisms. 


Diagnosis  and  Treatment  Considered  Generally   63 

Various  methods  have  been  tried  to  prevent  infection,  but  with 
no  great  success.  On  the  whole,  however,  there  has  been  a  good 
deal  of  improvement.  It  is  curious  that  the  same  difficulty  is 
found  on  operating  on  acute  appendix  abscess,  where  the  peri- 
toneum can  readily  combat  the  septic  condition  in  which  it  is 
left,  while  the  abdominal  wound  falls  a  victim  to  the  bacilli. 

Treatment  of  the  Peritoneal  Cavity. 

(3)  Abdominal   Drainage.- — Opinions    differ   about   this,   and 
personally  I  never  use  it,  nor  do  I  believe  that  it  has  any  points 
to  recommend  it.     When  speaking  of  abdominal  drainage,   I 
mean  the  ordinary  drain  to  the  pelvis  or  loin.    It  is  quite  another 
thing  to  tie  a  small  drain  to  a  suture  line  which  one  mistrusts, 
the  idea  of  which  is  to  form  a  local  track  in  the  case  of  a  leak. 

(4)  Flushing  the  Abdomen. — Some  surgeons  favour  this  pro- 
cedure, and  it  has  something  to  be  said  for  it  when  the  abdomen 
is  full  of  septic  blood.    At  the  same  time  it  is  difficult  to  carry 
out  efficiently  without  exposure  of  the  intestines.    In  small  local 
infections  without  blood  it  is  not  to  be  recommended. .   The 
cold  produced  by  ether  is  sufficient  to  damn  it,  even  if  it  could 
cleanse  the  abdomen  ;   a  small  amount  used  to  produce  leucocy- 
tosis  may  find  favour  with  some. 

Post-operative  Treatment. 

I  do  not  know  that  there  is  anything  particular  to  be  done 
to  the  patient  after  the  abdomen  is  closed.  Rest  and  quiet 
and  the  avoidance  of  all  needless  disturbance  are  to  be  aimed  at. 
The  question  of  infusion  or  transfusion  will  naturally  arise,  and 
in  some  cases  may  be  beneficial.  Most  people  treat  their  cases 
in  a  semi-recumbent  position.  Personally,  I  would  let  the 
patient  choose  his  own  posture.  As  to  the  administration  of 
morphia,  it  is  better  to  give  it  than  withhold  it  if  the  patient  is 
restless  or  in  pain. 

Most  interest  turns  on  the  condition  of  the  bowels.  Castor 
oil,  calomel,  and  pituitrin,  all  have  their  advocates.  There  can 
be  no  doubt  that  pituitrin  is  a  very  fine  purgative,  especially  if 
injected  into  the  muscles  ;  sometimes  it  requires  to  be  helped 
by  a  glycerin  enema.  Like  all  other  purgatives,  it  is  dependent 


64  War  Surgery  of  the  Abdomen 

for  its  action  on  a  healthy  condition  of  the  musculature  of  the 
bowels,  and  if  this  is  paralysed  either  by  shock  or  sepsis,  it  will 
fail  to  act.  For  my  own  part,  I  am  not  particularly  anxious 
about  the  opening  of  the  bowels,  and  am  fairly  convinced  that 
the  bowels  will  not  give  trouble  if  the  case  is  going  to  do  well  ; 
if  not — and  it  is  mostly  a  question  of  peritoneal  sepsis — no 
purgative  is  of  any  real  avail.  A  good  deal  of  discomfort  has 
been  needlessly  inflicted  by  attempts  to  make  the  bowels  act. 

Dilatation  of  the  stomach  is  a  fairly  common  complication, 
and  is  to  be  treated  by  gastric  lavage,  repeated  if  necessary. 

A  word  may  be  said  here  about  the  progress  of  the  patients 
after  operation.  Putting  aside  those  who  do  well  from  the  first, 
and  those  who  never  look  like  recovering,  the  post-operative 
cases  may  be  roughly  divided  into  three  classes  :  (1)  Patients 
who  do  well  for  thirty-six  hours  or  so,  then  go  through  a  critical 
period,  with  abdominal  distension,  vomiting,  and  a  rising  pulse. 
They  may  eventually  recover  or  succumb.  (2)  Those  who  are 
troubled  by  sickness  continuing  from  the  operation,  but  in  whom 
the  sickness  diminishes  and  the  pulse-rate  falls.  (3)  Those  who 
vary  in  an  astounding  manner  from  day  to  day,  so  that  one 
can  have  no  certainty  of  the  ultimate  result.  This  condition  is 
often  independent  of  the  condition  of  the  bowels,  which  may  be 
acting.  These  are  the  cases  spoken  of  by  Sampson  Handley 
in  his  paper  in  the  Lancet,  April  8th,  1916.  The  cases  referred 
to  by  him  were  those  of  pelvic  peritonitis,  in  which  the  lower 
segment  of  the  bowel  is  mostly  affected  ;  in  the  cases  under 
discussion,  unfortunately,  the  infection  is  often  in  the  upper 
portion  of  the  abdomen.  The  two  classes  of  case  do  not  seem 
to  be  quite  on  a  level,  even  if  we  admit  that  the  dilatation  of 
the  upper  segment  is  a  septic  and  not  a  nervous  phenomenon. 
However  this  may  be,  it  is  a  most  difficult  point  to  determine 
whether  operation  is  likely  to  do  good  or  not.  One  sees  so 
many  patients  go  through  a  critical  period  and  recover  that  one 
fears  to  proceed  to  secondary  operation  for  fear  of  turning  the 
balance  against  them.  It  has  been  tried  on  several  occasions, 
with  very  little  success.  If  it  is  done,  the  method  advocated  by 
Sampson  Handley  seems  to  be  the  method  of  choice. 


CHAPTER   V. 

WOUNDS   OF  HOLLOW  ALIMENTARY  ORGANS   AND   THEIR 

TREATMENT. 

Wounds  of  Particular  Organs.* 

(Esophagus. — Wounds  of  the  oesophagus  are  rarely  seen, 
while  those  of  the  pharynx  and  trachea  are  more  common. 
The  rarity  of  such  wounds  is  due  to  the  fact  that  antero- 
posterior  wounds  involve  the  spine  and  transverse  wounds 
the  great  vessels.  Some  of  the  lower  thorax  wounds  which  are 
accompanied  by  vomiting  may  be  wounds  of  the  oesophagus. 
In  one  case  of  a  fatal  abdomino-thoracic  wound  it  was  found 
that  the  oesophagus  had  been  torn  just  as  it  passed  through  the 
diaphragm.  Such  wounds  must  always  be  dangerous,  as,  even 
if  diagnosed,  access  to  them  is  exceedingly  difficult  either  by 
way  of  the  abdomen  or  across  the  chest. 

One  curious  case  may  be  quoted  where  a  man  was  hit  in  the 
back  about  the  fourth  right  interspace.  He  was  treated  for  a 
thoracic  wound,  as  there  were  no  localising  symptoms.  Two 
days  later  he  passed  per  anum  the  core  of  a  bullet,  and  the  day 
following  the  mantle. 

Stomach. 

FREQUENCY. — In  965  operated  cases  the  stomach  was 
perforated  eighty-two  times.  In  fifty-five  instances  it  was  the 
only  hollow  viscus  damaged. 

*  (a)  The  number  of  times  that  injuries  of  solid  organs  complicate  injuries  of 
other  organs  (both  hollow  and  solid)  is  probably  understated,  though  the  proportion 
of  such  complicating  injuries  of  solid  organs  to  one  another  is  approximately  correct. 

(6)  In  speaking  of  the  causes  of  death,  no  reference  has  been  made  to  injuries  other 
than  abdominal ;  but  in  many  cases  the  fatal  result  must  be  largely  put  down  to 
injuries  other  than  those  of  the  abdomen. 

(c)  The  lesions  of  hollow  organs  enumerated  in  the  tables  and  in  the  text  are  per- 
foritive  lesions.  Every  single  viscus  was  bruised  or  had  its  outer  coats  injured  on 
many  other  occasions. 

W.S.A.  5 


66  War  Surgery  of  the  Abdomen 

SITUATION  OF  THE  INJURY. — This  is  shown  in  Table  VIII.  :— 
TABLE  VIII. 


Site  of  Wound. 

Alone. 

With  other 
Hollow  Viscera. 

Anterior  wall 

27 

8 

Posterior  wall 

5 

1 

Anterior  and  posterior  walls 

14 

10 

Greater  curvature 

2 

1 

Lesser  curvature 

2 

1 

Cardia 

2 

1 

Near  oesophagus 

2 

— 

Lesser  curvature  and  posterior  wall    .  . 

1 

— 

Wall,  not  stated 

— 

5 

Total 

55 

27 

The  number  of  times  both  walls  have  been  perforated  and 
other  hollow  viscera  (both  small  and  large  gut)  wounded  is  rather 
remarkable,  when  one  remembers  how  innocuous  antero- 
posterior  epigastric  wounds  were  supposed  to  be. 

The  fact  that  the  posterior  wall  may  be  wounded  alone,  or  in 
conjunction  with  the  posterior  surface  of  the  transverse  colon,  is 
of  importance,  as  neither  of  these  places  is  visible  unless  a  special 
search  is  made ;  such  wounds  have  been  missed  at  operation. 

ASSOCIATED  WOUNDS  OF  OTHER  ORGANS  :— 

Hollow  Viscera. — Small  gut,  19  ;  colon,  13  (colon  and  small 
gut  together,  5). 

The  jejunum  is  the  part  of  the  small  gut  most  frequently  hit, 
very  often  within  a  short  distance  of  its  commencement.  These 
high  injuries  are  especially  caused  by  side-to-side  wounds  which 
catch  the  bowel  as  it  lies  high  up  jn  the  abdomen  in  front  of  the 
kidney.  When  the  projectile  pursues  a  more  vertical  course, 
the  ileum  is  also  injured,  or  injured  alone. 

The  transverse  colon  is,  more  frequently  than  any  other  part 
of  the  great  gut,  injured  along  with  the  stomach  ;  but  parts  so 
far  distant  as  the  pelvic  colon  and  caecum  have  also  been  hit. 
The  splenic  flexure  escapes  more  often  than  one  would  expect. 
Sometimes,  in  addition  to  the  transverse,  the  ascending  or 


Wounds  of  Hollow  Alimentary  Organs       67 

descending  colon  is  wounded.    Such  wounds  are  caused  by  pro- 
jectiles having  a  highly  inclined  side-to-side  course. 

Solid  Viscera. — Liver,  15  ;  spleen,  5  (4  fatal) ;  pancreas,  3  ; 
kidney,  4. 

A  few  examples  of  complicated  injuries  may  be  given  : — 

Anterior  wall — spleen — kidney  (died). 

Stomach — pancreas — kidney  (died). 

Stomach — liver — kidney  (died). 

Anterior  and  posterior  walls — transverse  colon — small  gut 
(died). 

Anterior  wall — transverse  colon — jejunum  (died). 

Lesser  curvature — descending  colon — liver  (died). 

Anterior  wall — caecum. 

Anterior  wall — descending  colon  (died). 

Lesser  curvature  near  oesophagus — top  of  spleen  (died). 

Anterior  wall — lower  pole  of  left  kidney. 

The  few  occasions  on  which  a  stomach  and  spleen  wound 
occurs,  considering  the  close  association  of  these  viscera,  are 
remarkable  and  suggest  that  such  injury  is  very  fatal. 

NATURE  OF  THE  WOUNDS.- — The  stomach  affords  many  types 
of  wound,  nearly  all  easily  explained  by  the  nature  of  the 
projectile  and  the  course  it  takes.  Sometimes  the  stomach  wall 
is  exposed  by  the  carrying  away  of  the  anterior  abdominal  wall. 
At  other  times  prolapse  of  the  stomach  takes  place,  accompanied 
by  that  of  the  colon,  small  gut,  and  spleen. 

Bullets  passing  in  an  antero-posterior  direction  make  small 
perforations.  Shrapnel  balls  cause  larger  perforations,  the  edges 
of  which  are  more  excoriated  than  is  the  case  with  bullet  wounds ; 
the  larger  size  and  rounder  form  of  the  ball  cause  it  to  bruise 
the  wall  before  it  bursts  its  way  through.  Shell  and  bomb 
fragments  make  wounds  commensurate  with  their  size  and 
shape.  When  the  axis  of  the  flight  of  the  projectile  is  more  or 
less  parallel  to  the  walls  of  the  stomach,  the  wounds  become 
larger — ^sometimes  a  linear  slit,  sometimes  a  linear  slit  followed 
by  a  perforation,  to  which  the  name  of  "  note  of  exclamation 
wound  "  may  be  given.  The  linear  type  of  wound  is  nearly 
always  on  the  anterior  surface.  When  the  projectile  passes  in 
through  the  epigastrium  and  out  by  the  axilla,  the  slits  tend  to 

0-2 


68 


War  Surgery  of  the  Abdomen 


become  parallel  to  the  greater  curvature.  When  the  missile 
takes  a  more  vertical  course,  the  wounds  are  inclined  at  an  angle 
to  the  greater  curvature,  and  the  anterior  wall  of  the  stomach, 
or  its  antral  portion,  may  be  almost  completely  divided.  Pro- 
jectiles hitting  the  greater  or  lesser  curvature  in  an  antero- 


FIG.  10. — Bullet  wound  of  anterior  wall  of  stomach.  The  wound  extended  half  an 
inch  on  to  the  posterior  wall.  The  right  gastro-cpiploic  artery  was  divided. 
Under  care  of  Captain  Hamilton  Drummond.  (Medical  Society  and  Brit. 
Journ.  of  Surgery.) 

posterior  direction  sometimes  cause  rather  extensive  V-shaped 
injuries  involving  both  walls.  Occasionally  the  wound  is  a 
valvular  one,  preventing  the  escape  of  the  contents. 

Bruises  or 'cuts  in  the  peritoneum  or  muscular  coats  are  not 
infrequently  met  with. 


Wounds  of  Hollow  Alimentary  Organs       69 

Gangrene  of  the  wall  has  resulted  from  injury  to  the  gastro- 
splenic  omentum. 

The  mucous  membrane  does  not  pout  when  the  wounds  are 
small ;  but  in  the  case  of  linear  wounds  it  becomes  extruded 
just  as  it  does  when  one  incises  the  stomach  wall  in  doing  a 
gastro-jejunostomy. 

Bleeding. — Wounds  of  the  stomach  are  accompanied  by  very 
severe  haemorrhage,  which  may  come  from  the  organ  itself  or 
from  vessels  or  organs  near  it.  The  haemorrhage,  as  a  rule,  does 
not  come  from  the  actual  wall,  but  from  the  vessels  as  they  run 
up  and  down  its  surface.  The  bleeding  may  take  place  either 
into  the  stomach  or  into  the  peritoneal  cavity. 

SYMPTOMS. — Vomiting  is  a  very  constant  feature ;  in  fact,  the 
stomach  is  the  only  viscus  which  almost  always  furnishes  this 
symptom.  One  is  often  surprised  that  vomiting  is  possible, 
when  the  size  of  the  wound  in  the  organ  is  considered.  There  is 
sometimes  an  escape  of  gas  from  the  wound,  but  no  particular 
diagnostic  value  is  to  be  attached  to  the  presence  or  absence  of 
liver  dulness.  The  escape  of  contents  has  already  been  dealt  with. 
It  should  be  noted  that  bile  may  escape  from  a  stomach  wound. 

TREATMENT. — Operation  is  to  be  advised  in  almost  all  cases. 
The  only  possible  exceptions  are  those  cases  of  low  thoracic 
wounds  where  it  is  judged  from  the  track  of  the  missile  that 
the  stomach  is  wounded  near  the  oesophagus  or  in  the  upper 
air-containing  part.  Some  such  cases  do  get  well  by  them- 
selves, and  one  rather  hesitates  to  operate  because  of  the 
difficulty  encountered  and  disturbance  caused. 

The  standard  incision  is  a  paramedian  one.  The  closure  of 
wounds  of  the  horizontal  portion  is  easy,  but  the  farther  to  the 
left  and  the  nearer  to  the  cardia  the  more  difficult  does  the 
operation  become.  This  difficulty  points  to  the  advisability  of 
using  the  transpleural  route  when  wounds  of  the  cardia  are  in 
question,  especially  if  the  missile  has  entered  through  the  thorax 
and  has  only  involved  the  immediate  neighbourhood. 

As  a  rule,  one  can  tell  if  the  posterior  wall  is  likely  to  have 
been  involved.  If  this  is  the  case,  or  if  there  is  any  doubt,  the 
posterior  surface  must  be  explored  through  the  gastro-colic 
omentum  in  the  usual  way.  The  suture  of  such  wounds  may  be 


yo  War  Surgery  of  the  Abdomen 

very  difficult.  Wounds  of  the  lesser  curvature  involving  both 
coats  are  also  troublesome  to  suture.  There  is  no  need  to  excise 
the  wounds  unless  they  happen  to  be  very  ragged.  Gastro- 
enterostomy  may  be  necessary  in  cases  of  wounds  dividing 
the  antral  portion  or  the  duodenum,  or  in  some  cases  of  narrowing 
of  the  stomach ;  this  should  only  be  done  in  cases  of  very 
evident  necessity. 

PROGNOSIS. — The  maximum  period  of  successful  suture  after 
receipt  of  the  wound  is  thirty-six  hours,  and  the  prognosis 
depends  largely  on  the  amount  of  haemorrhage  that  has  taken 
place,  and  on  the  association  of  other  wounded  organs.  The 
amount  of  peritonitis  present  does  not  depend  very  directly  on 
the  length  of  time  between  the  injury  and  the  operation. 

Possibility  of  Spontaneous  Recovery. — This  has  already  been 
admitted. 

SECONDARY  COMPLICATIONS. — A  secondary  haemorrhage  was 
not  a  very  uncommon  event,  and  was  met  with  as  early  as  the 
fifth  day  ;  it  is  much  less  frequently  seeji  now  than  formerly. 

In  the  British  Medical  Journal  of  April  8th,  1916,  Lieutenant- 
Colonel  T.  R.  Elliott  and  Captain  Herbert  Henry  made  some 
important  remarks  on  the  "  After-history  of  both  Operated  and 
Unoperated  Gastric  Wounds."  They  showed  that  sutured  and 
non-sutured  wounds  and  contusions  are  subject  to  ulceration, 
secondary  haemorrhage,  and  perforation.  Secondary  haemor- 
rhage occurred  on  the  sixth,  twelfth,  and  fifteenth  days 
respectively ;  death  occurred  on  the  ninth,  twenty-sixth,  and 
twenty-fifth  days,  the  first  from  haemorrhage  and  the  last 
two  from  peritonitis.  Colonel  Elliott  thinks  this  points  to 
the  necessity  of  careful  feeding,  and  especially  to  the  with- 
holding of  extractives.  Sub-diaphragmatic  abscesses  have  been 
met  with,  but  are  not  so  common  as  might  be  supposed — even 
in  the  pre-operative  days,  according  to  Sir  George  Makins. 

MORTALITY  AND  CAUSES  OF  DEATH. — The  mortality  in  all 
cases  where  the  stomach  was  wounded  is  60 '9.  In  cases  un- 
complicated with  wounds  of  other  hollow  viscera,  the  mortality 
is  52'7  per  cent,  (in  the  first  500  cases  the  mortality  was  43 '7 
per  cent.).  In  those  complicated  with  lesions  of  other  hollow 
organs,  the  mortality  rises  to  77*8  per  cent. 


Wounds  of  Hollow  Alimentary  Organs       71 

The  increased  gravity  of  multiple  wounds  of  different  organs 
is  well  shown,  for  while  the  stomach  has  a  mortality  of  52 '7 
per  cent.,  the  small  intestine  of  65 '9  per  cent.,  and  the  great  gut 
of  58'7  per  cent.,  the  combination  of  such  injuries  shows  a  mor- 
tality of  100  per  cent,  in  this  series  of  cases. 

If  all  the  published  statistics  are  massed  one  gets  138  cases 
in  which  the  stomach  was  wounded,  with  88  deaths  and  50 
recoveries— a  mortality  of  63*7.  The  numbers  of  cases,  in  which 
the  stomach  was  the  only  viscus  wounded  are  not  sufficient  to 
furnish  any  reliable  inference,  but  the  deaths  and  recoveries  are 
almost  equal. 

When  the  effect  on  the  mortality  of  an  associated  wound  of  a 
solid  organ  is  considered,  the  result  is  not  so  clear.  Thus  in 
38  cases,  of  which  17  recovered  and  21  died,  we  find  that  there 
were  5  cases  of  liver  wound  among  the  recoveries,  and  5  among 
the  deaths.  Among  the  deaths  there  were  also  4  cases  of 
injury  of  the  spleen,  1  of  the  pancreas  and  liver,  1  of  the  pancreas 
and  kidney,  and  1  of  the  pancreas.  The  complication  of  spleen 
injury  would  appear  to  be  a  grave  one. 

Out  of  29  fatal  cases  uncomplicated  with  injuries  of  hollow 
organs,  the  actual  cause  of  death  in  25  cases  was  as  follows  : 
shock  and  haemorrhage,  15  ;  peritonitis,  5  ;  lung  trouble,  2  ; 
gas  gangrene,  3. 

Small  Intestine. 

FREQUENCY. — In  965  operated  cases  the  small  gut  was  found 
wounded  363  times.  In  255  instances  it  was  the  only  hollow 
viscus  wounded. 

ASSOCIATED  WOUNDS  OF  OTHER  ORGANS. — Stomach,  19 
(5  with  colon)  ;  colon,  89  (5  with  stomach)  ;  rectum,  4  ;  bladder, 
16  ;  liver,  8  (gall-bladder  twice  involved)  ;  kidney,  7  ;  spleen,  3. 

The  sites  of  the  colon  wounds  were  as  follows  :  caecum,  13  ; 
ascending  colon,  6  ;  hepatic  flexure,  7  ;  transverse  colon,  23  : 
splenic  flexure,  3  ;  descending  colon,  13  ;  pelvic  colon,  18. 

NATURE  OF  THE  WOUNDS. — There  does  not  seem  to  be  any 
great  difference  in  the  frequency  with  which  the  jejunum  and 
ileum  are  wounded,  though  perhaps  the  figures  at  my  disposal 
are  too  small  to  draw  a  comparison,  as  the  site  of  the  lesion  has 


72  War  Surgery  of  the  Abdomen 

not  been  stated  with  sufficient  frequency.  In  the  case  of  the 
duodenum,  one  may  state  with  accuracy  that  it  was  wounded 
16  times  among  363  small-gut  injuries. 

The  injuries  of  the  ileum  would  appear  to  be  more  serious 
than  those  of  the  jejunum.  This  is  also  supported  by  the  fact 
that  cases  suitable  for  suture  are  more  common  in  the  upper 
than  in  the  lower  part — a  circumstance  to  be  expected  when  the 
size  of  the  tube  and  thickness  of  the  walls  of  the  jejunum  are 
compared  with  the  smallness  of  the  tube  and  the  thinness  of 
the  walls  of  the  ileum.  The  multiplicity  of  the  coils  in  the  latter 
also  favours  more  extensive  injury. 

The  character  of  the  small-gut  wounds  varies  in  some  degree 
with  the  projectile  that  caused  them,  but  not  to  the  extent  that 
one  might  expect.  A  bullet  may  inflict  as  Severe  an  injury  as  a 
piece  of  high-explosive  shell.  It  used  to  be  thought  that  a 
patient  shot  with  a  bullet  had  a  better  chance  than  one  injured 
by  a  shell  fragment.  The  present  war  has  proved  this  to  be  a 
mistake.  As  a  matter  of  fact,  the  least  severe  wounds  are 
caused  by  the  small  fragments  of  bomb  and  shell. 

Bullet  Injuries.' — The  injury  may  be  complete  or  incomplete ; 
i.e.,  it  may  open  the  lumen,  or  it  may  only  score,  bruise,  or  tear 
the  outer  coats. 

The  most  common  injuries  are  the  perforations  made  by  the 
bullet  striking  the  intestine  at  right  angles  to  its  long  axis.  Here 
there  are  two  perforations,  through  which  the  mucous  mem- 
brane pouts  to  form  a  small  round  rosette.  Some  holes  are  so 
small  as  to  hardly  admit  the  kind  of  bullet  that  made  them ; 
through  such  holes  the  mucous  membrane  does  not  pout. 
As  the  flight  of  the  bullet  becomes  more  inclined  to  the  transverse 
or  long  axis  of  the  gut  the  perforations  become  slits,  but  there 
are  still  two  separate  wounds.  These  wounds  gape  somewhat, 
and  the  mucous  membrane  overlaps  the  cut  muscular  coat,  so 
that  a  considerable  mucous  surface  meets  the  eye.  The  general 
appearance  still  suggests  a  rosette,  but  with  one  axis  longer 
than  the  other.  The  two  slits  may  enlarge  until  the  continuity 
of  the  intestine  is  only  maintained  by  two  narrow  strands  of 
the  wall. 

In  other  cases  there  is  only  one  wound,  involving  different 


Wounds  of  Hollow  Alimentary  Organs       73 


portions  of  the  circumference  of  the  intestine  ;  it  may  reach 
from  near  the  mesenteric  border  to  near  the  free  margin,  or 
involve  the  free  margin  only.  In  other  cases  the  free  margin  is 
slit  right  back  to  the  mesenteric  border,  so  that  only  a  narrow 
strip  of  wall  remains.  The  last  piece  to  be  divided  is  usually 
the  attached  portion ;  here  thece  is  a  wide  gaping  wound  with 


FIG.  11. — Jejunum:  gunshot  perforation,  resected  nine  hours  after  injury.  It 
shows  the  protrusion  of  the  mucosa  which  usually  occurs.  Death.  (Captain 
Hamilton  Drummond.) 

an  extensive  exposed  mucous  surface.  In  extreme  cases  the  gut 
is  completely  divided.  In  another  extreme  form  of  injury  the 
intestine  is  only  represented  by  a  long,  narrow,  and  ragged  strip 
of  bowel. 

The  explanation  of  the  transverse  direction  of  the  lesions  is  to 
be  found  in  the  looped  arrangement  of  the  small  intestine, 
whereby  the  greater  part  of  the  tube  lies  in  a  vertical  direction. 


74 


War  Surgery  of  the  Abdomen 


As  a  man  is  usually  shot  cither  from  side  to  side  or  from  before 
backwards,  the  missile  will  hit  the  intestine  at  right  angles.  If 
the  bullet  takes  an  up-and-down  direction,  one  meets  with 
longitudinal  lesions  of  the  gut. 


Fid.  12. — Wounds  of  small  intestine  caused  by  a  bullet.  P.M.  specimen.  Under 
care  of  Captain  J.  B.  Haycraft.  (Medical  Society  of  London  and  Brit.  Journ. 
of  Surgery.) 

In  any  one  case  all  types  of  injury  may  be  encountered. 
Shell  Fragments. — These  cause  wounds  of  all  varieties,  gene- 
rally commensurate  with  their  size.     Perhaps  the  wounds  are 


Wounds  of  Hollow  Alimentary  Organs       75 

more  irregular  than  those  caused  by  bullets,  and  the  clean 
transverse  divisions  of  the  gut  more  rare. 

Shrapnel  Balls. — These  cause  ragged  perforations  or  tears  of 
moderate  size. 

Bombs.- — Bomb  injuries  often  cause  small  multiple  wounds, 
which  are  frequently  collected  together  over  a  short  length  of  the 
gut.  The  mucous  membrane  very  often  does  not  pout,  as  the 
hole  is  so  small. 


FIG.  13. — Jejunum :  lacerated  wounds  caused  by  fragment  of  rifle  grenade  shown 

in  the  drawing. 

Lesions  of  the  Mesentery. — These  are  of  all  sorts  and  varieties, 
from  simple  perforations  to  irregular  tears.  Destruction  of  the 
mesentery  may  occur  without  a  lesion  of  the  bowel  and  of  itself 
necessitate  resection. 

Intimate  Nature  of  the  Lesion. — The  eversion  of  the  mucous 
membrane  is  due  to  its  redundancy,  and  also,  apparently  from 
an  examination  of  microscopic  sections,  to  a  retraction  of  the 
longitudinal  coat  (Captain  J.  W.  McNee  and  Captain  J.  S.  Dunn). 
Microscopic  examination  of  the  wounded  edges  shows,  further, 


76  War  Surgery  of  the  Abdomen 

that  the  lesion  is  a  very  local  one  ;  in  fact,  the  appearance  is  no 
more  remarkable  than  one  would  expect  if  the  intestine  had  been 
cut  with  a  pair  of  scissors :  it  usually  consists  of  a  blood  infiltra- 
tion in  the  neighbourhood  of  the  wound.  The  mucous  coat 
stains  well  and  distinctly  right  up  to  the  tear. 

There  is  nothing  to  suggest  "  remote  disturbance  "  or  the 
necessity  for  a  wide  excision  of  tissue. 

NUMBER  OF  INJURIES. — In  124  cases  the  average  number  of 
lesions  was  4  '8 ;  in  40  cases  in  which  resection  was  performed  the 
average  number  was  6 '8,  and  in  84  cases  treated  by  suture  it 
was  4*1 .  Single  lesions  are  the  exception.  The  greatest  number  of 
lesions  was  20,  and  6  feet  of  intestine  were  successfully  resected 
by  Captain  Owen  Richards.  Captain  John  Fraser  also  success- 
fully sutured  14  individual  lesions  and  a  hole  in  the  bladder. 
The  lesions  are  usually  collected  close  together,  but  sometimes 
they  are  disposed  in  two  or  three  groups  which  necessitate 
multiple  resections.  Occasionally  they  are  scattered  over  the 
entire  length  of  the  small  intestine  with  wide  spacings. 

The  length  of  bowel  involved  may  be  gathered  from  the 
following  figures,  which  represent  in  25  consecutive  cases  the 
amount  resected  (in  inches)  :  30,  48,  18,  24,  30,  48,  48,  108,  30, 
18,  48,  8,  20,  24,  36,  5,  48,  48,  24,  30,  48,  24,  16,  30,  24.  In 
some  of  these  cases,  in  addition,  other  lesions  were  sutured  when 
they  lay  at  some  distance  from  the  more  severe  injury. 

SYMPTOMS. — There  is  nothing  more  to  be  added  to  what  has 
been  said  under  the  heading  of  "  Diagnosis  of  Intraperitoneal 
Damage  "  (see  p.  51). 

TREATMENT. — A  long  paramedian  incision  is  the  rule,  except 
in  those  cases  which  have  been  dealt  with  when  the  site  of  the 
incision  was  discussed. 

The  actual  operative  technique  in  the  abdomen  is  as  follows  : 
Any  blood  present  must  be  got  rid  of,  and  the  bleeding  stopped. 
As  a  rule,  the  whole  length  of  the  small  intestine  must  be 
explored,  with  the  possible  exception  of  those  cases  of  side-to- 
side  wounds  involving  one-half  of  the  abdomen  where  a  trans- 
verse incision  has  been  used.  In  such  cases,  if  there  is  no  blood, 
and  the  whole  length  of  the  missile  track  can  be  seen,  it  may  be 
possible  to  dispense  with  the  routine  examination. 


Wounds  of  Hollow  Alimentary  Organs       77 


FIG.  14. — Section  of  wound  of  small  gut.  It  shows  the  eversion  of  the  edge  of  the 
lesion.  The  mucous  membrane  and  other  coats  are,  except  for  some  blood 
infiltration,  normal  right  up  to  the  cut  edge.  (Specimen  by  McNee  and  Dunn.) 
(Medical  Society  of  London  and  Brit.  Journ.  of  Surgery.) 


78  War  Surgery  of  the  Abdomen 

The  caecum  or  duodeno-jejunal  junction  is  first  picked  up  and 
brought  out  of  the  wound  ;    then  the  intestine  is  inspected, 


Flu.  15.  -Jejunum  from  the  same  case  as  Fig.  11 :  thrombosis  of  vessels  from  injury 
to  the  mesentery  at  two  points.  There  were  twelve  perforations  of  the  small  gut. 
Resection  of  4  feet ;  end-to-end  union.  Death.  (Captain  Hamilton  Drummond.) 

taking  care  to  look  at  both  sides  and  to  replace  the  examined 
part  within  the  abdomen.  If  a  small  hole  is  found,  and  the  gut 
beyond  it  for  6  or  8  inches  is  intact,  the  hole  is  sewn  up.  If  the 


Wounds  of  Hollow  Alimentary  Organs       79 

next  lesion  that  is  encountered  is  a  small  one,  the  process  may 
be  repeated.  If,  however,  the  first  lesion  is  a  large  one,  it  is 
better  to  cover  it  up  with  gauze  and  a  clamp,  and  then  proceed 
with  the  examination  of  the  whole  length,  for  a  big  lesion, 
if  quickly  followed  by  another,  may  necessitate  resection,  and  the 
amount  to  be  resected  can  only  be  determined  when  the  total 
injuries  are  known. 

When  the  small  intestine  has  been  dealt  with,  the  stomach  is 
explored,  if  there  is  any  likelihood  of  its  being  injured.  The 
colon  is  dealt  with  last  of  all,  as  it  is  here  that  an  artificial 
anus  may  be  very  likely  necessary.  If,  however,  a  transverse 
incision  has  been  used,  it  is  best  to  deal  with  the  great-gut 
lesion  first,  and  so  limit  the  possibility  of  further  spreading  the 
infection. 

Suture  or  Resection. — Suture  should  be  practised  when  possible ; 
small  discrete  injuries,  however  numerous,  should  be  sutured  ; 
and  it  is  probably  best  if  the  injuries  are  severe,  or  even  com- 
plete, provided  they  are  not  too  near  together.  It  is  also 
better  to  narrow  the  bowel  than  to  resect,  even  if  it  involves  a 
lateral  anastomosis. 

Resection  should  be  reserved  for  cases  where  the  bowel  is 
practically  destroyed,  where  there  are  several  severe  injuries 
or  complete  divisions  close  together,  and  where  injuries 
extending  into  the  mesentery,  or  infarction  of  vessels,  give  no 
choice. 

The  following  figures  show  the  length  in  inches  resected  in 
some  successful  cases  taken  in  order  :  36,  15,  36,  8,  8,  44,  12,  36, 
9,  18,  8. 

Multiple  resections  in  this  series  have  always  been  fatal, 
though  there  have  been  some  successful  cases  in  other  series. 

TABLE  IX. — To  show  the  Results  of  Suture  and  Resection  in  Cases 
uncomplicated  by  Wounds  of  other  Hollow  Viscera. 


Operation  . 

To  Base. 

Died. 

Mortality. 

Resection 

26 

87 

76-9 

Suture 

59 

71 

54-6 

8o  War  Surgery  of  the  Abdomen  • 

The  greater  fatality  of  the  resection  cases  depends  largely  on 
the  initial  injury,  especially  on  the  loss  of  blood  ;  but  in  reading 
over  the  cases,  one  finds  many  instances  of  resection  where  the 
condition  of  the  patient  was  at  any  rate  fair,  and  yet  a  fatal 
result  followed.  It  seems  as  if  resection  definitely  increased  the 
shock. 

Circular  v.  Lateral  Suture. — The  old  controversy  is  still 
unsettled.  Results  are  as  follows  (Table  X.),  the  balance  being 
in  favour  of  lateral  anastomosis,  but  the  numbers  are  small  :— 

TABLE  X. — Circular  and  Lateral  Suture  compared. 


Operation. 

To  Base. 

Died. 

Circular  enterorrhaphy 

18 

69 

Lateral  anastomosis 

8 

18 

If  a  lateral  suture  is  used,  it  would  seem  best  to  let  the  two 
portions  of  the  bowel  overlap  well,  so  as  to  get  the  lateral 
opening  in  the  gut  a  little  distance  away  from  the  ends,  where 
motility  is  last  to  return. 

Technique  of  Suture  or  Resection. — A  single  row  of  stitches  is 
practically  always  sufficient  in  suture.  Care  should  be  taken  to 
close  the  rent  in  a  transverse  direction  to  save  narrowing  the 
lumen. 

Many  operators  have  found  that  a  single  suture  line  is  suffi- 
cient also  in  resection. 

Owing  to  the  nature  of  the  contents  of  the  upper  bowel, 
greater  care  is  probably  needed  in  suturing  the  jejunum  than 
the  ileum. 

Primary  Short-circuiting;  Entcrostomy. — These  operations 
have  been  done  at  the  primary  operation  to  relieve  a  dilated 
upper  segment,  or  as  purely  prophylactic  measures.  They  are 
not  to  be  recommended,  though  possibly  useful  if  the  upper 
part  of  the  bowel  is  distinctly  dilated  from  sepsis.  They  have, 
I  believe,  been  abandoned. 

Secondary  Short  Circuit. — This  has  been  done  on  several 
occasions,  but  with  little  success  (one  in  this  series). 


Wounds  of  Hollow  Alimentary  Organs       81 

Treatment  of  a  Prolapsed  Knuckle. — In  the  early  days  there 
was  some  difference  of  opinion  as  to  what  was  the  best  treat- 
ment for  this  condition.  Nowadays,  with  the  establishment 
of  the  operative  treatment,  most  probably  the  right  thing  to 
do  is  to  open  the  abdomen  and  deal  with  the  lesions  which  are 
found. 

Sepsis. — To  judge  from  the  peritonitis  present,  it  may  have 
made  considerable  headway  in  four  hours,  or  it  may  be  prac- 
tically absent  after  twenty-six  hours. 

MORTALITY  AND  CAUSES  OF  DEATH  : — 

TABLE   XI.- — To   show  Increasing  Mortality   of  Complications. 


Sits  of  Wound. 

To  Base. 

Died. 

Mortality. 

Per  cent. 

Small  gut 

87 

168 

65-9 

Small  gut  and  stomach 

4 

10 

) 

Small  gut  and  colon 

22 

63 

\    7-1-1 

Small  gut  and  rectum 

— 

4 

Small  gut,  stomach,  and  colon 

— 

5 

Small  gut  and  bladder 

1 

15 

TABLE  XII. — To  show  the    Causes  of  Death  in  a  Consecutive 
Series  of  Resections  and  Sutures  respectively  (uncomplicated). 


L/Ause  oi  ueatn. 

Kesection. 

Suture. 

Peritonitis    .  . 

14 

14 

Missed  lesion 

•   •                     •    • 

1 

3 

Shock  and  haemorrhage 

15 

11 

Gas  gangrene  of  belly  wall 

5 

4 

Asthenia 

.    .                    .    . 

1 

1 

Paralytic  ileus 

,    . 

— 

2 

Pulmonary  embolism 

— 

2 

Pneumonia  .  . 

.    . 

—  - 

1 

Bronchitis    .  . 

.    .                    .    . 

— 

.2 

Gangrene  of  lung 

.  . 

— 

1 

The  suture  line  has  on  very  few  occasions  shown  any  fault, 
and  where  peritonitis  has  supervened,  it  must  be  put  down  to 
other  causes. 

W.S.A.  6 


82  War  Surgery  of  the  Abdomen 

TABLE  XIII. — To  show  the  Average  Number  of  Lesions  in  Fatal 
and  Successful  Cases  respectively. 


Operation. 

To  Base. 

Died. 

Resection 

4-1 

7-1 

Suture 

3-45 

4-27 

The  Different  Parts  of  the  Small  Intestine  compared. — When 
the  comparative  dangers  of  a  wound  of  the  duodenum,  jejunum, 
and  ileum  are  considered,  the  figures  at  my  disposal  are  not  very 
adequate,  since  the  jejunum  and  ileum  have  not  been  distin- 
guished a  sufficient  number  of  times.  A  wound  of  the  duodenum 
is  a  fatal  injury,  as  in  eleven  cases  of  wound  of  this  viscus  only 
two  recovered.  As  regards  the  lower  part  of  the  small  gut,  a 
wound  of  the  jejunum  would  appear  to  be  the  least  dangerous. 

High  Mortality  of  Associated  Bladder  Wounds. — A  wound  of 
the  bladder  seems  to  be  an  extremely  serious  complication  of 
the  wounds  of  the  small  gut.  In  the  present  series  there  were 
sixteen  instances  of  wounds  of  this  viscus.  and  all  but  one  died. 
This  is  due,  partly  at  any  rate,  to  the  fact  that  when  the  bladder 
is  injured  the  lesion  of  the  small  gut  is  generally  very  serious 
and  situated  in  the  closely  coiled  ileum.  On  the  other  hand, 
half  the  fatal  cases  complicated  lesions  of  the  small  gut  that 
were  treated  by  suture,  and  presumably,  therefore,  were  not 
very  serious.  This  would  tend  to  show  that  there  is  an  inherent 
danger  in  a  wound  of  the  bladder  itself.  Very  likely  the  extra 
time  taken  to  deal  with  the  lesion  is  a  great  factor  in  the  result. 
In  addition,  there  is  often  a  fractured  pelvis  with  these  injuries. 

Complicating  Wounds  of  the  Spleen. — There  were  three  cases 
complicated  by  splenic  injury,  and  two  of  them  were  fatal. 
With  this  exception,  the  solid  organs  do  not  seem  to  have  played 
a  great  part  in  the  mortality. 

Large  Intestine. 

FREQUENCY. — In  965  operated  cases  the  colon  was  wounded 
252  times.  In  155  cases  it  was  the  only  part  of  the  alimentary 
tract  hit. 


Wounds  of  Hollow  Alimentary  Organs       83 


ASSOCIATED  WOUNDS  OF  OTHER  VISCERA  :— 

Hollow  Viscera. — Table  XIV.  gives  the  number  of  times  that 
the  stomach  and  small  gut  suffered  together  with  the  colon. 

The  comparatively  small  number  of  times  that  the  splenic 
flexure  was  injured  is  somewhat  remarkable.  It  may  be  that 
the  difficulty  of  differentiating  between  transverse  and  descend- 
ing colons  and  splenic  flexure  may  have  something  to  do  with 
this,  and  that  some  of  the  injuries  of  the  two  former  parts  should 
really  have  been  described  as  lesions  of  the  latter  ;  the  observa- 
tions were  made,  however,  by  a  number  of  operators. 

TABLE  XIV. — To  show  Hollow  Viscera  injured  with  Different 

Parts  of  Colon. 


Site  of  Wound. 

Wounded  with 
Stomach. 

Wounded  with 
Small  Gut. 

Alone. 

Total. 

Caecum 

2 

13 

16 

31 

Ascending  colon     .  . 

.  —  - 

5 

36 

41 

Hepatic  flexure 

1 

7 

24 

32 

Transverse  colon    .  . 

4 

22 

15 

41 

Splenic  flexure 

— 

3 

18 

21 

Descending  colon  .  . 

2 

9 

17 

28 

Pelvic  colon 

— 

18 

23 

41 

Position  not  stated 

4 

12 

6 

22 

Totals 

13 

89 

155 

257 

(a)  There  were  several  cases  in  which  two  parts  of  the  colon  were  wounded;  the 
highest  wound  only  has  been  given.  (6)  There  were  five  cases  in  which  the  stomach 
and  small  gut  were  both  wounded  along  with  the  colon.  The  total  colon  wounds 
therefore  number  five  less  than  the  grand  total  given  in  the  table. 

Solid  Organs. — The  solid  organs  do  not  often  seem  to  be  injured 
at  the  same  time  as  the  colon.  The  kidney  was  hit  seven  times, 
the  liver  seven,  and  the  spleen  seven.  The  bladder  was  injured 
four  times  (for  two  cases  of  associated  wounds  of  the  bladder 
and  rectum  see  "Rectum").  The  ureter  was  injured  in  two 
cases. 

NATURE  OF  INJURIES.— The  injuries  of  the  large  intestine  are 
really  similar  to  those  of  the  small  gut.  The  differences  that  are 
to  be  noted  are  due  to  (1)  its  larger  size,  (2)  its  absence  of  coils, 

6-2 


84  War  Surgery  of  the  Abdomen 

(3)  its  absence  of  mesentery,  and  (4)  its  proximity,  in  some 
portion  of  its  extent,  to  bone. 

(1)  The  large  size  of  the  tube  leads  to  a  preponderance  of  tears 
or  perforations  ;   but  instances  are  met  with  in  which  the  whole 
lumen  is  completely  divided,  and  this  happens  both  in  the  fixed 
portion  and  in  that  endowed  with  the  mesentery.     Complete 
division  is  due  to  a  collapsed  condition  of  the  gut,  when  it  may 
be,  as  is  well  known,  but  little  bigger  than  the  small  intestine  ; 
the  transverse,  descending,  and  pelvic  colons  are  the  parts  most 
frequently  divided. 

(2)  The  absence  of  coils  means  that  multiple  injuries  are  not 
common,  and,  when  they  occur,  are  not  so  numerous  as  in  the 
small  intestine.     The  multiple  injuries  are  found  at  the  bends. 
In  one  case  which  may  be  mentioned  there  were  six  perforations : 
two  in  the  ascending  colon,  two  in  the  hepatic  flexure,  and  two 
in  the  transverse  colon.     In   another  case  there  were  three 
wounds  in  the  caecum  and  ascending  colon,  and  two  in  the  hepatic 
flexure.    In  a  third  case  there  were  five  wounds  in  the  pelvic 
colon. 

(3)  The  absence  of  the  mesentery,  over  the  great  part  of  the 
colon,  means  a  frequent  occurrence  of  retroperitoneal  wounds. 
These  are  difficult  to  find,  and  are  largely  responsible  for  the 
heavy  mortality.     The  partially  covered  portion  of  the  small 
intestine — namely,  the  duodenum — has  likewise  a  very  large 
mortality. 

(4)  The  proximity  to  bone  leads  to  wounds  of  the  caecum,  the 
two  vertical  colons,  and  the  pelvic  loop,  by  spicules  of  bone  ; 
and,  as  has  been  pointed  out,  these  injuries  are  apt  to  be  over- 
looked,  because  the  perforations   in  the  peritoneum  are  not 
conspicuous. 

Infarction. — This  type  of  injury  is  met  with  in  the  small 
intestine,  but  I  think  it  is  rather  commoner  in  the  large.  The 
caecum  with  the  ileum  and  the  descending  and  iliac  colons  have 
all  been  found  in  this  state. 

Ulcer ation  of  the  Mucous  Membrane  associated  with  Rupture  of 
the  Muscle  Coats. — Captains  H.  Drummond  and  J.  S.  Dunn  have 
called  attention  to  this  condition.*  The  ulceration  may  occur 

*  Brit.  Journ.  of  Suegrry,  vol.  v.,  No.  17,  1917. 


Wounds  of  Hollow  Alimentary  Organs       85 


Fu;.  16. — Mucous  surface  of  caput 
coecum  and  part  of  ascending 
colon  in  Case  5.  There  are  three 
fairly  extensive  ulcers  on  the 
posterior  wall,  one  being  in  the 
caput.  The  base  of  each  ulcer 
is  formed  by  the  submucous 
layer,  and  is  much  infiltrated 
with  blood.  (Brit.  Journ.  of 
Surgery.) 


FIG.  17. — The  muscular  wall  of  the  colon 
underlying  the  ulcers  shown  in 
Fig.  16.  The  posterior  longitudinal 
band  of  muscle  is  torn  across  in 
two  places  (B  and  C),  and  the  torn 
ends  have  retracted,  drawing  with 
them  the  fibres  of  the  circular  layer. 
It  is  seen  that  these  lesions  in  the 
muscle  correspond  exactly  in  site 
with  the  two  ulcers  in  the  ascending 
colon.  The  tear  in  the  outer  longitu- 
dinal band,  marked  A,  was  un- 
associated  with  ulceration.  The 
arrangement  of  the  muscular  lesions 
in  this  case  affords  good  evidence 
that  they  were  produced  by  indirect 
violence,  as  all  of  them  were  caused  by 
one  rifle  bullet.  (Brit.  Journ.  of 
Surgery.) 


86  War  Surgery  of  the  Abdomen 

as  soon  as  seven  hours  after  wounding.  It  seems  to  be  caused 
by  a  cutting  off  of  the  blood  supply  to  the  mucous  membrane 
by  rupture  of  the  underlying  muscle  coat.  It  is  especially 
interesting  because  the  ruptured  muscle  may  be  separated  from 
the  actual  track  of  the  missile  by  a  layer  of  undamaged  tissue. 
The  authors  attribute  the  damage  to  a  dragging  effect  pro- 
duced by  the  projectile  and  transmitted  through  strands  of 
fibrous  tissue  or  to  sudden  impact  on  a  gas-filled  sac. 

The  rapidity  with  which  the  mucous  membrane  ulcerates 
after  losing  its  blood  supply  is  very  remarkable. 

These  lesions  may  account  for  some  of  the  fistulse  that  form 
in  the  colon  when  it  has  apparently  escaped  injury. 

One  case  may  be  quoted  from  the  original  article  :— 

"  Case  5. — G.  was  wounded  by  a  rifle  bullet  at  11.30  p.m.  on 
June  17th,  1916,  and  was  admitted  to  hospital  six  hours  later, 
much  collapsed.  A  small  round  entry  wound  was  present  in 
the  left  buttock,  and  the  exit  wound,  which  was  larger  and 
irregular,  was  in  the  right  mid-axillary  line  at  the  level  of  the 
costal  margin. 

"  Laparotomy  was  performed  shortly  after  admission.  There 
was  no  evidence  of  injury  of  the  abdominal  viscera,  except  some 
haemorrhage  on  the  wall  of  the  caecum  and  behind  the  perito- 
neum of  the  right  flank.  Some  blood-stained  urine  was  passed 
a  few  hours  later.  Death  occurred  twenty-one  hours  after 
wounding. 

"It  was  found  that  the  wound  track  passed  from  the  left  buttock 
through  the  sacro-sciatic  notch  and  the  upper  part  of  the  sacrum, 
through  the  belly  of  the  right  psoas  muscle,  and  thence  between 
the  right  kidney  and  the  ascending  colon.  Neither  of  the  latter 
viscera  had  been  directly  touched  ;  a  layer  of  retroperitoneal 
fat  a  quarter  of  an  inch  in  thickness  intervened  between  the 
track  and  the  colon  wall.  There  was  cellulitis  and  gangrene 
around  the  wound  track  in  the  retroperitoneal  tissue,  and  films 
and  cultures  made  later  from  this  material  showed  abyndant 
gas-forming,  anaerobic  bacilli.  The  capsule  of  the  right  kidney 
was  intact,  but  two  subcapsular  lacerations  were  present  in  the 
cortex  on  the  anterior  aspect  of  the  lower  pole.  The  ascending 
colon  exhibited  externally  only  some  haemorrhage  on  its  inner 


Wounds  of  Hollow  Alimentary  Organs       87 

side.  When  this  portion  of  bowel  was  opened,  two  large  areas 
of  ulceration  were  observed  on  the  posterior  wall,  while  a  third 
was  seen  in  the  caput  caecum  (Fig.  16).  The  two  uppermost 
ulcers  lay  almost  directly  over  the  bullet  track.  Each  ulcer 
penetrated  deeply  into  the  submucous  coat,  but  not  quite  through 
it ;  the  bases  were  necrotic,  and  dark  with  haemorrhage.  The 
mucosa  and  submucosa  were  then  dissected  off  from  the  muscular 
layers.  By  this  means  it  was  shown  (Fig.  17)  that  underneath 
the  middle  and  uppermost  ulcers  the  posterior  longitudinal 
band  of  muscle  had  been  sharply  torn  across.  The  torn  ends 
were  widely  retracted,  and  the  circular  fibres,  though  not 
lacerated,  were  drawn  apart  with  them,  so  as  to  leave  a  complete 
wide  gap  in  the  muscular  layers.  Each  of  these  lesions  was 
associated  with  some  haemorrhage,  and  the  exposed  retroperito- 
neal  tissue  was  foul  and  gangrenous.  A  like  muscular  lesion  was 
also  observed  in  the  outer  longitudinal  band,  opposite  the  level 
of  the  upper  ulcer,  but  it  was  unaccompanied  by  haemorrhage 
or  by  ulceration  of  the  mucosa.  In  relation  to  the  ulcer  in  the 
caput  caecum,  there  was  only  slight  tearing  of  the  circular  fibres, 
with  some  haemorrhage." 

Escape  of  Contents.- — The  large  intestine  is  often  laden,  but 
the  condition  of  the  contents  renders  massive  escape  less  frequent 
than  it  would  otherwise  be  ;  however,  taken  all  in  all,  escape 
from  the  large  intestine  is  more  frequent  than  from  the  small, 
especially  when  the  caecum  and  ascending  colon  are  involved. 

Character  of  the  Lesions  in  Different  Parts  of  the  Colon. 

Ccecum.' — There  has  been  a  fair  number  of  caecal  wounds. 
Most  of  them  have  been  small  in  extent,  and  have  lent  them- 
selves to  suture.  In  other  cases  the  wounds  have  been  so  big 
as  to  necessitate  an  artificial  anus.  In  one  case  there  was 
bruising  of  a  transposed  caecum.  In  a  good  many  cases  there 
was  a  large  retroperitoneal  haemorrhage  ;  this  injury  was  in 
one  instance  accompanied  by  acute  dilatation  of  the  sto  ach. 

Transverse  Colon.' — All  kinds  of  wounds  are  met  with  here, 
from  a  simple  single  lesion  to  complete  division.  True  antero- 
posterior  wounds  are  not  very  common,  and  as  a  rule  the 
transverse  colon  is  struck  obliquely,  the  bullet  passing  through 


88  War  Surgery  of  the  Abdomen 

the  anterior  part  of  the  lumen.  It  has  already  been  stated  that 
such  wounds  are  often  accompanied  by  lesions  of  the  stomach 
and  small  intestine.  It  was  owing  to  this  association  that  so 
few  wounds  of  this  portion  of  the  colon  arrived  at  the  Base  in 
the  preoperative  days. 

The  posterior  surface  is  sometimes  wounded,  and  this  may  be 
overlooked  unless  it  is  borne  in  mind  that  such  an  injury  is 
possible,  for  it  is  not  obvious  unless  a  special  search  is  made. 
Bleeding  from  the  vessels  supplying  this  portion  of  the  bowel  is 
fairly  frequent. 

Vertical   Colons   (Ascending   and   Descending   Colon). — It   is 
convenient  to  take  these  two  portions  together,  as  they  have  no 
mesentery.    Both,  and  especially  the  descending  colon,  lie  rather 
farther  from  the  lateral  line  than  would  appear.     The  wound 
may  be  completely  intraperitoneal  or  extraperitoneal,  or  both 
combined.     The  actual  lesions  are  perforations,  slits,  tears,  or 
complete  divisions.    Perforations  are  most  commonly  met  with 
in  side-to-side  wounds,  and  complete  division  in  antero-posterior 
wounds.      All   varieties   may   be   complicated   with   small-gut 
injuries.     At  the  Base,   Makins  noticed  that  wounds  of  the 
ascending  colon  were  more  common  than  other  colon  wounds  ; 
and  he  attributed  the  frequency  of  the  ascending  colon  wounds, 
compared  with  those  of  the  descending,  to  the  latter  being  more 
often  accompanied  by  small-gut  injuries,  owing  to  the  fact  that 
the  small  gut  overlies  it.     This  explanation  seems  to  a  certain 
degree  just.     Out  of  forty-one  wounds  of  the  ascending  colon, 
only   five   were    complicated    by    small-gut    lesions  ;     whereas 
twenty-eight  wounds  of  the  descending  colon  had  associated 
small-gut  injuries  in  nine  instances.    On  the  other  hand,  wounds 
of  the  ascending  colon  are  actually  more  frequent  than  those  of 
the  descending — forty-one  to  twenty-eight.     The  comparative 
rarity  of  descending  colon  wounds  may  also  be  due  to  the  fact 
that  the  descending  colon  lies  so  deep  that  any  bullet  passing 
from  side  to  side  and  involving  it  would  traverse  a  coronal 
plane  situated  so  far  back  in  the  body  as  to  involve  the  spine 
and  great  vessels.     Again,  the  descending  colon  is  usually  much 
smaller  than  the  ascending,  so  that  it  offers  less  of  a  mark  for 
the  missile. 


Wounds  of  Hollow  Alimentary  Organs       89 

The  intraperitoneal  wounds  of  the  vertical  colons  are  fairly 
easy  to  find  and  to  deal  with  if  a  suitable  incision  is  used.  The 
extraperitoneal  are  very  difficult,  and  most  probably  are  more 
often  missed  than  any  other.  The  extraperitoneal  wound, 
which  may  be  small  and  valvular,  is  difficult  to  find  because 
it  lies  in  a  mass  of  areolar  tissue  ;  and  the  difficulty  will  be 
greatly  increased  when  this  tissue  is  infiltrated  with  blood,  as 
it  so  often  is. 

Hepatic  Flexure.- — Next'  to  the  transverse  colon  the  hepatic 
flexure  is  the  easiest  of  all  to  deal  with,  as  it  lies  fairly  superfi- 
cially. Its  form  leads  to  multiple  injuries. 

Splenic  Flexure.  —  This,  from  its  position,  is  the  hardest 
of  all  the  large  intestine  to  deal  with,  and  even  with  the  best- 
placed  incision  it  is  difficult  to  examine  properly  without 
mobilisation. 

Pelvic  Colon. — This  portion  of  the  large  intestine  is  anatomi- 
cally more  like  the  small  intestine  than  any  other  part  of  the 
colon,  and  the  lesions  are  somewhat  similar.  There  are  slits, 
perforations,  or  complete  divisions ;  and  it  is,  next  to  the  trans- 
verse colon,  most  often  complicated  with  multiple  small-gut 
injuries.  Fracture  of  the  pelvis,  so  often  associated,  increases 
the  gravity  of  the  case.  I  have  been  struck  with  the  great 
variations  in  position,  as  shown  by  the  different  situations  of 
the  wounds  of  the  gut  in  different  cases  in  which  the  bullet  has 
taken  a  similar  direction . 

SYMPTOMS. — The  symptoms  of  intraperitoneal  wounds  of  the 
large  gut  are  similar  to  those  of  the  small  intestine.  A  great 
difference  lies  in  the  behaviour  of  the  extraperitoneal  wounds, 
where  all  grades  of  infection  are  met  with.  Sometimes  we  have 
cases  of  acute  sepsis,  with  or  without  gas  formation,  which  are 
fatal  in  a  few  hours.  Such  cases  are  often  past  help  when  they 
arrive.  They  are  cold,  blanched,  and  clammy,  and  the  pulse  is 
running  ;  in  fact,  their  appearance  often  suggests  acute  haemor- 
rhage. To  this  class  of  case  Captain  John  Fraser,  M.C.,  has 
given  the  apt  name  of  "  colon  septicaemia." 

The  dangerous  sepsis — shown  by  the  high  mortality — of  the 
colon  anus,  when  formed  in  the  vertical  colons,  has  led  some 
operators  to  always  make  an  attempt  to  close  the  bowel.  Un- 


90  War  Surgery  of  the  Abdomen 

fortunately  the  damage  is  already  done  when  the  case  has  come 
under  treatment.  In  other  cases  the  symptoms  are  less  acute, 
or  are  not  seen  when  the  case  has  arrived.  Some  with  a  small 
single  loin  wound,  arriving  late  and  left,  do  well  even  though  a 
faecal  fistula  forms.  In  others  signs  of  intoxication  and  local 
infection  appear,  both  of  which  may  be  relieved  by  incision, 
with  the  possible  establishment  of  a  fistulous  opening.  Sepsis 
is  sometimes  due  to  infective  material  carried  in  with  the 
missile,  and  not  to  a  communication  with  the  bowel. 

In  all  cases  it  is  well  to  err  on  the  side  of  making  a  good 
opening  for  drainage. 

TREATMENT. — The  fact  that .  some  unoperated  colon  cases 
did  arrive  at  the  Base  and  recover  cannot  now  be  advanced  as 
a  ground  for  abstention  except  in  cases  which  arrive  late. 

Incision. — It  may  still  be  necessary  to  use  a  paramedian 
incision  for  a  general  exploration  of  the  abdomen,  for  the 
exclusion  of,  or  for  dealing  with,  other  injuries.  The  transverse 
and  pelvic  colons  are  best  dealt  with  from  such  an  incision,  as 
these  lesions  are  commonly  associated  with  those  of  the  small 
gut.  It  may  be  necessary  to  supplement  this  median  incision 
with  one  toward  the  side  of  the  body  when  either  of  the 
vertical  colons  is  found  wounded.  When  the  missile  has  only 
traversed  the  loin,  the  horizontal  incision  is  by  far  the  best. 
The  rectus  sheath  incision  may  be  preferred  by  some  for 
exploration  of  the  hepatic  and  splenic  flexures  ;  but  the  asso- 
ciation of  kidney  injuries  with  these  wounds  makes  a  hori- 
zontal incision  more  expedient,  as  the  kidney  can  be  clealt  with 
in  the  posterior  extremity  of  the  wound,  whereas  an  attempt 
to  remove  the  kidney  through  the  anterior  incision  is  not  very 
convenient. 

Open  wounds  involving  the  loin,  and  possibly  involving  the 
colon,  may  be  dealt  with  by  local  enlargement ;  but,  in  the 
absence  of  X-rays,  a  median  incision,  to  exclude  other  injuries, 
will  most  probably  be  required. 

Method  of  dealing  with  the  Lesions. — This  is  largely  deter- 
mined by  three  factors  :  (a)  the  size  of  the  tear  ;  (b)  the 
situation  of  the  tear  ;  and  (c)  the  state  of  the  patient,  in  whom 
other  injuries  may  have  been  dealt  with. 


Wounds  of  Hollow  Alimentary  Organs       91 

Ccecurr, . — Here  it  is  better  to  suture  if  possible,  but  to  provide 
adequate  drainage  if  there  is  any  possibility  of  an  extraperito- 
neal  wound.  In  wounds  of  the  extraperitoneal  part  which  have 
only  been  found  after  mobilisation  of  the  colon,  even  if  suture 
is  possible,  it  is  advisable  to  shut  off  the  general  peritoneal 
cavity  by  a  line  of  sutures  joining  the  anterior  surface  of  the 
bowel  to  the  lateral  abdominal  wall  and  provide  good  posterior 
drainage. 

Transverse  Colon. — The  transverse  colon  is  the  most  easily 
dealt  with  of  all  the  colon  lesions.  When  the  wound  is  large, 
the  question  is  really  one  of  whether  suture  or  an  artificial  anus 
is  the  quicker  method  of  dealing  with  the  case,  for  here  probably 
other  lesions  have  been  dealt  with,  and  the  condition  of  the 
patient  is  not  likely  to  be  very  good. 

Vertical  Colons. — Small  lesions  are  easily  closed  if  intra- 
peritoneal.  Wounds  involving  the  extraperitoneal  portions  of 
the  gut  are  dangerous,  and,  even  if  they  are  closed  by  suture, 
adequate  external  drainage  must  be  provided.  No  doubt  suture 
is  the  ideal  method,  but  it  is  often  very  difficult,  and  in  some  cases 
impossible,  owing  to  the  loss  of  substance.  Here  the  only  plan 
is  to  make  an  artificial  anus.  In  the  retrocolic  haematomata  so 
often  met  with,  it  is  often  impossible  to  exclude  colon  injuries  ; 
these  therefore  must  be  freely  drained. 

Hepatic  Flexure. — The  same  rules  apply  here  as  to  the  trans- 
verse colon,  the  only  point  being  that  mobilisation  of  the  flexure 
may  be  necessary  to  get  at  the  lesion. 

Splenic  Flexure. — This  is  the  hardest  of  all  to  manage  satis- 
factorily, both  on  account  of  the  difficulty  in  reaching  it,  and  of 
the  mobilisation  necessary  to  find  the  hole.  An  artificial  anus  is 
often  necessary. 

Pelvic  Colon. — This  is  easily  dealt  with  in  its  upper  portion. 
Care  must  be  taken  to  exclude  wounds  on  the  border  of  the 
gut  uncovered  with  mesentery.  In  one  case  a  minute  frag 
ment  of  bomb  had  entered  the  mesentery,  which  was  here 
loaded  with  fat,  at  a  little  distance  from  the  bowel,  and  had 
penetrated  into  the  bowel  at  the  mesenteric  attachment.  The 
Trendelenburg  position  greatly  facilitates  treatment  of  low-lying 
injuries. 


92  War  Surgery  of  the  Abdomen 

TABLE  XV. — Showing  Colon  Injuries  uncomplicated  with 
Wounds  of  other  Hollow  Viscera,  the  Site  of  the  Lesion  and 
the  Treatment. 


Site  of  Lesion. 

Sutured. 

Artificial 
Anus. 

Total. 

Caecum 

13 

3 

16 

Ascending  colon 

25 

11 

36 

Hepatic  flexure 

16 

8 

24 

Transverse  colon 

13 

2 

15 

Splenic  flexure 

10 

8 

18 

Descending  colon 

9 

8 

17 

Pelvic  colon 

16 

7 

23 

Position  not  stated 

— 

6 

6 

An  interesting  fact  in  the  above  table  is  the  small  number  of 
artificial  ani  that  it  was  found  necessary  to  establish  at  the  site 
of  a  lesion  in  the  transverse  colon  when  no  other  hollow  viscus 
had  been  damaged. 

Proximal  Colostomy. — It  seemed  probable,  when  starting  work, 
that  proximal  colostomies  would  have  a  much  wider  application 
than  has  been  found  to  be  the  case.  They  are,  of  course,  useful 
in  limiting  the  amount  of  septic  absorption  in  cases  of  wounds 
of  the  vertical  colons  ;  but,  as  has  been  pointed  out,  this  tissue 
is  already  infected  at  the  time  the  cases  come  under  treatment. 
One  does  not  feel  inclined  to  make  an  extra  opening  in  the  bowel, 
often  at  the  end  of  a  long  operation.  Proximal  colostomy  to 
be  of  any  use  must  be  complete,  and  it  probably  finds  its  best 
application  in  those  cases  of  loin  wounds  on  the  left  side  in  which 
sepsis  develops  late,  and  in  rectal  injuries.  It  has  been  used 
considerably  at  the  Base  for  faecal  fistulas  developing  from 
colon  wounds  when  suture  has  failed  to  close  the  rent. 

Of  ten  proximal  colostomies  done  at  the  Front  five  were  for 
rectal  wounds  and  five  for  colon  injuries  distal  to  the  trans- 
verse colon. 

A  transverse  colostomy  is  to  be  recommended.  A  csecostomy 
has  proved  of  little  value  at  the  Front,  but  has  been  useful,  I 
understand,  at  the  Base. 

MORTALITY  AND  CAUSES  OF  DEATH. — The  mortality  of  colon 


Wounds  of  Hollow  Alimentary  Organs      93 

wounds,  uncomplicated  with  other  lesions  of  the  alimentary 
tube,  is  58 "7  per  cent.  ;  it  may  be  compared  with  that  of  the 
small  intestine,  which  is  65 '9  per  cent.  The  colon  mortality  is 
greatly  raised  by  that  of  the  colon  anus,  for,  whereas  suture  of 
the  colon  has  a  mortality  only  just  over  50  per  cent.,  that  of  colon 
anus  is  73-5  per  cent. 

These  figures  must  not  be  taken  to  mean  that  a  colostomy  is 
a  necessarily  dangerous  operation,  but  only  that  sepsis  is  likely 
to  cause  death  in  those  injuries  that  require  a  colostomy.  Infec- 
tion has  already  started  where  the  colostomy  has  been  performed. 

It  is  interesting  to  compare  the  above  figures  with  those  given 
by  Makins  in  the  preoperative  days. 

Table  XVI.  clearly  indicates  that  in  the  preoperative  period 
a  man  with  a  colon  wound  had  the  better  chance,  and  this 
advantage  still  continues,  though  the  margin  is  narrower. 

TABLE  XVI. — Showing  the  Difference  between  the  Mortality  of 
Small  and  Large  Intestine  Wounds  in  the  Preoperative 
and  Operative  Periods  respectively. 


Site. 

Preoperative 
Period  (Base). 

Operative 
Period  (Front). 

Per  cent. 

Per  cent. 

Small  intestine 

86 

65-9 

Great  intestine 

38-7 

58-7 

No  definite  comparison  can  be  made  between  the  different 
parts  of  the  colon,  as  the  figures  are  not  large  enough. 

TABLE    XVII. — Showing    Comparative    Mortality    of  Different 
Portions  of  the  Colon  (Suture  and  Artificial  Anus). 


Site  of  Lesion. 

To  Base. 

Died. 

Caecum.  ... 

8 

7 

Ascending  colon 

14 

16 

Hepatic  flexure 

8 

11 

Transverse  colon 

5 

10 

Splenic  flexure 

4 

7 

Descending  colon 

8 

6 

Pelvic  colon 

8 

10 

94 


War  Surgery  of  the  Abdomen 


Rectum  (the  last  12  cm.  of  the  Alimentary  Canal). 

FREQUENCY.- — In  965  operated  cases,  the  rectum  was  wounded 
21  times. 
ASSOCIATED  INJURIES  : — 

TABLE  XVIII. — A  Table  of  Rectal  Injuries. 


Viscera  wounded. 

To  Base. 

Died. 

Remarks. 

Rectum  alone 
Rectum  and  small  gut 

7 

10 
4 

Three    were    intraperi- 
toneal  entirely. 
All  intraperitoneal,    all 
sutured. 

It  is  remarkable  that  the  bladder  was  only  wounded  twice 
in  conjunction  with  the  rectum.  The  same  thing  is  to  be  noted 
in  the  case  of  the  pelvic  colon,  which  was  only  wounded  once  in 
association  with  the  bladder. 

CHARACTER  OF  THE  LESIONS. — Wounds  of  the  rectum  can  be 
roughly  divided  into  three  classes  :  (1)  those  that  may  be  said 
to  complicate  wounds  of  the  buttocks,  the  ischial  fossae,  or  the 
perineum  ;  (2)  those  caused  by  missiles  that  traverse  the  pelvic 
portion  of  the  abdomen  ;  (3)  the  ulcerative  lesions  described  by 
Drummond  and  Dunn  (see  p.  84).  All  these  are  likely  to  be 
accompanied  by  fractures  of  the  pelvic  bones,  spicules  of  which 
may  wound  the  gut. 

(1)  The  missile  may  be  a  bullet  or  a  small  or  large  shell  frag- 
ment. In  the  last  case  especially  the  external  damage  may  be 
very  great,  and  a  large  portion  of  the  gluteal  region  torn  away  ; 
the  anus  and  lower  portion  of  the  rectum  may  be  completely 
avulsed,  or  the  lumen  opened  on  one  side  only.  If  the  pro- 
jectile is  small,  the  sphincter  may  be  left  intact,  and  the  lumen 
of  the  tube  perforated  above  that  muscle.  The  peritoneum 
may  or  may  not  be  opened.  The  danger  most  to  be  feared 
is  septic  absorption,  but  on  the  whole  extensive  wounds  of 
the  buttocks  do  not  do  so  badly  now.  On  the  other  hand, 
there  is  still  considerable  danger  of  gas  gangrene  in  the  gluteus 
maximus. 

Wounds  involving  the  sacrum,  although  not  opening  the  gut, 


Wounds  of  Hollow  Alimentary  Organs      95 

have  proved  very  fatal  from  septic  infection  of  the  presacral 
areolar  tissue.  On  the  other  hand,  it  has  happened  on  several 
occasions  that  pieces  of  shell,  which  have  been  felt  protruding 
into  the  rectum  on  its  postero-lateral  aspect,  have  been  removed 
from  rectum  and  recovery  followed  without  any  further  surgical 
procedure. 

(2)  The  partially  covered  rectum  may  be  wounded  extraperi- 
toneally  or  intraperitoneally,  or  both.  Missiles  that  cause 
such  injuries  take  a  side-to-side,  antero-posterior,  or  semi- 
vertical  direction.  If  side  to  side,  the  entrance  and  exit  wounds 
lie  on  the  postero-external  aspect  of  the  buttocks,  and  whether 
the  missile  catches  the  extraperitoneal  or  intraperitoneal  surface, 
or  both,  depends  on  the  plane  traversed  and  the  obliquity  of 
this  plane  to  the  coronal  plane  of  the  body. 

The  side-to-side  wounds  are  deceptive,  leading  one  to  think, 
from  the  posterior  situation,  that  they  have  missed  the  bowel. 

TREATMENT. — The  two  classes  of  cases  require  separate 
consideration. 

(1)  The  treatment  of  injuries  complicating  buttock  wound 
follows  the  ordinary  lines  of  treatment  of  wounds  in  general, 
and  consists  in  excising  all  damaged  tissue.  In  some  cases  it 
may  be  possible  to  close  the  rent  in  the  bowel  or  sphincter ;  in 
other  cases  it  may  be  beneficial  to  lay  open  the  lower  end  of  the 
canal  by  dividing  the  sphincter  (Makins).  If  the  peritoneum 
has  been  opened,  something  may  be  done  by  shutting  off  the 
abdominal  cavity  by  sutures.  The  question  of  colostomy  must 
be  considered,  and  its  expediency  must  be  determined  by  the 
difficulty  or  otherwise  of  keeping  the  patient  clean  and  com- 
fortable. It  will  be  mostly  called  for  in  those  cases  in  which 
the  whole  lower  segment  of  the  bowel  has  been  carried  away 
and  the  torn  bowel  is  lying  patent  in  the  pelvis.  In  such  cases 
the  lumen  may  be  closed  by  sutures  or  a  purse-string  ligature, 
which  device  will,  at  all  events,  tend  to  limit  contamination 
of  the  pelvis  while  adhesions  are  forming.  If  a  colostomy  is 
necessary,  transverse  colostomy  is  the  operation  of  choice, 
because  of  the  ease  of  cleansing  the  opening,  of  fitting  a  belt 
(which  will  then  lie  on  the  natural  line  of  the  waist),  and  of 
subsequent  closure  if  this  is  desirable. 


96  War  Surgery  of  the  Abdomen 

(2)  Treatment  of  wounds  of  the  rectum  caused  by  projectiles 
that  have  traversed  the  pelvis.  There  will  not  be,  as  a  rule, 
much  doubt  that  an  exploratory  coeliotomy  is  the  correct  pro- 
cedure ;  but  if  any  doubt  exists,  as  in  side-to-side  and  semi- 
vertical  wounds,  it  will  be  well  to  err  on  the  side  of  operation. 
If  the  peritoneal  surface  has  escaped,  the  abdomen  can  be 
closed  and  the  wound  opened  up  from  the  exterior.  Anterior 
wounds  can  often  be  sutured,  though,  from  their  depth  in  the 
pelvis,  great  difficulty  may  be  experienced.  A  drain  down  to 
the  lesion  is  a  wise  precaution  in  all  cases.  The  most  difficult 
cases  of  all  are  those  which  involve  the  rectum  at  the  very 
bottom  of  Douglas'  pouch,  as  here  a  reliable  suture  is  often 
practically  impossible.  It  has  been  suggested  that  it  might  be 
good  treatment  to  introduce  a  tube  through  the  anus  up  to  the 
site  of  the  lesion,  and  to  cut  off  the  bottom  of  Douglas'  pouch, 
by  suturing  the  peritoneum  over  it. 

The  question  of  a  colostomy  must  be  determined  by  the 
probability  or  not  of  the  suture  holding. 

Fortunately,  associated  bladder  wounds  are  rare,  but  a 
simultaneous  suprapubic  cystostomy  and  a  colostomy  must  be 
avoided  if  possible. 

Protrusion  of  Omentum  and  Viscera. 

By  this  is  meant,  not  the  exposure  of  the  abdominal  contents 
through  a  gap  in  the  abdominal  wall,  but  their  prolapse  through 
a  wound,  often  comparatively  small. 

OMENTUM.- — As  would  be  expected,  the  omentum  is  most 
frequently  seen  in  this  connection.  It  appears  in  large  or  small 
amounts  in  wounds  situated  all  over  the  abdomen,  also  in  those 
situated  in  both  hypochondriac  regions,  where  it  reaches  the 
outside  of  the  body  through  the  interspaces  or  through  broken 
ribs  where  one  hardly  would  expect  to  see  it.  Sometimes  in 
abdomino-thoracic  wounds  it  passes  into  the  pleura  and  plugs 
the  hole  in  the  diaphragm.  There  are  two  methods  by  which 
it  is  extruded:  it  is  either  (1)  carried  out  by  the  projectile,  or 
(2)  driven  out  through  the  entrance  or  exit  wound  by  the  intra- 
abdominal  pressure.  The  latter  is  the  most  common. 

In  one  case,  where  a  shell  fragment  had  entered  above  the 


Wounds  of  Hollow  Alimentary  Organs      97 


FIG.  18. — Rectum  showing  large  perforation  on  its  anterior  or  vesical  aspect  caused 
by  fragment  of  shell  entering  over  the  sacral  region  and  lodging  at  the  base 
of  the  prostate. 

umbilicus  In  the  mid-line  and  had  come  out  in  the  right  loin 
behind  the  lateral  line  of  the  body,  the  omentum  was  so  firmly 
carried  into  the  long  obliqwe  exit  wound  that  it  required  consider- 


W.S.A. 


98  War  Surgery  of  the  Abdomen 

able  force  to  release  it  ;   it  was,  in  fact,  strangulated  within  the 
abdominal  wall,  though  none  of  it  showed  externally. 

Before  operation  became  the  rule  it  was  usual  to  leave  omental 
tags  to  slough  off,  and  probably  this  is  still  the  best  course  to 
pursue  if  the  cases  are  seen  late.  If  seen  early,  it  is  best  to  treat 
such  cases  as  other  abdominal  wounds,  and  explore.  In  several 
instances  where  this  has  been  done  the  intestine  has  been  found 
wounded. 

STOMACH.- — This  has  been  found  herniated  by  itself,  and  in 
association  with  the  spleen,  splenic  flexure,  and  small  intestine. 
In  one  case  where  it  was  wounded  and  prolapsed,  it  was  success- 
fully sutured  and  replaced,  though  too  much  of  the  abdominal  wall 
had  been  carried  away  to  allow  the  external  opening  to  be  closed. 

Protrusions  of  the  upper  viscera  are  accompanied  by  a  good 
deal  more  shock  than  is  protrusion  of  the  small  gut. 

LIVER.' — This  organ  has  also  been  partly  herniated. 

SMALL  INTESTINE. — Next  to  the  omentum,  the  small  gut  is 
most  frequently  herniated,  and,  as  in  the  case  of  the  omentum, 
it  may  be  carried  out  or  expelled.  Sometimes  a  knuckle  lying 
outside  has  been  actually  wounded  ;  in  other  cases  the  extruded 
part  has  remained  intact,  but  there  have  been  numerous  lesions 
in  the  small  gut  within  the  abdomen. 

If  seen  early,  the  ordinary  rules  apply,  and  the  abdomen 
should  be  opened  and  the  lesions  repaired  ;  if  seen  later — 
over  twenty-four  hours — it  is  not  probable  that  anything  can 
be  done,  but  still  it  is  better  perhaps  to  explore  if  the  condition 
of  the  patient  justifies  it.  A  great  deal  of  small  gut  can  be 
prolapsed  without  excessive  shock.  A  man*  wounded  six  hours 
previously,  with  the  greater  part  of  his  small  gut  on  his  belly 
wall,  had  a  pulse  of  100,  and  was  in  very  fair  condition. 

COLON. — The  transverse  colon  has  been  herniated,  and  in  one 
case  the  gut  was  tightly  constricted  in  the  wound  ;  as  the 
injury  was  two  days  old,  the  constriction  was  relieved,  and  an 
aritficial  anus  established. 

Behaviour  of  the  Omentum  in  Abdominal  Wounds. 

Some  attempt  has  been  made  to  study  the  movements  of  this 
organ,  and  some  observations  have  ..been  made  by  Captains 


Wounds  of  Hollow  Alimentary  Organs      99 

Drummond  and  Fraser.  Where  the  wounds  are  in  the  upper 
part  of  the  abdomen  the  omentum  rolls  itself  up  into  a  transverse 
pillow.  If  the  wounds  are  in  the  lower  part  it  remains  spread 
out  over  the  intestines.  Cases  are  operated  on  so  quickly  now 
that  the  omentum  has  no  time  to  find  the  leak  and  attach  itself. 
In  the  early  days  it  was  constantly  found  glued  to  the  lesion, 
and  it  was  not  .until  the  parts  were  disturbed  that  the  contents 
of  the  upper  dilated  intestine  escaped. 


7—2 


CHAPTER   VI. 


WOUNDS   OF  SOLID   ALIMENTARY  ORGANS   AND   SPLEEN. 

Liver. 

FREQUENCY. — In  965  abdominal  operations  the  liver  was 
wounded  163  times,  and  148  of  these  were  uncomplicated.  To 
these  must  be  added  23  cases  in  which  no  operation  was  done, 
but  in  which  the  liver  was  almost  certainly  wounded. 

ASSOCIATED  WOUNDS  OF  OTHER  ORGANS. — These  are  shown 
in  Table  XIX.  It  is  probable  that  the  liver  was  wounded  in 
association  with  other  organs  rather  more  frequently  than  the 
table  shows.  A  liver  wound  is  often  a  minor  complication  of  a 
much  more  grave  lesion,  and  in  the  pressure  of  work  it  is  natural 
that  only  the  more  serious  injury  should  have  fixed  itself  in  the 
operator's  mind.  But  when  allowance  has  been  made  for  this, 
the  small  number  of  associated  injuries  is  somewhat  remarkable. 

NATURE  OF  INJURIES. — A  good  many  cases  of  rupture  by 
horse  kicks  have  been  seen  (though  not  included  in  this  series)  ;• 
but  most  of  the  wounds  are  caused  by  projectiles,  sometimes 
aggravated  by  fractured  ribs  driven  in  by  the  missile.  The 
wounds  are  of  all  types,  from  a  simple  perforation  or  an  avulsion 
of  fragments,  especially  of  .the  anterior  edge,  to  an  almost 
complete  disruption. 

TABLE    XIX. — The  Number  of  Times    Different   Organs  were 
injured  in  conjunction  with  the  Liver. 


Viscus  injured  with  Liver. 

To  Base. 

Died. 

Result  not 
known. 

Stomach 

5 

6 

4 

,,         and  small  gut.  . 

— 

1 

— 

,,         small  gut,  and  colon 

— 

a 

— 

,,        and  colon 

—  ' 

i 

•  — 

Small  gut            

— 

i 

— 

..         and  colon 

— 

4 

— 

Colon 

2 

5 

— 

Kidney 

3 

9 

2 

Pancreas 

— 

2 

-  —  • 

Solid  Alimentary  Organs  and  Spleen        IOT 

The  wounds  arc-  usually  commensurate  with  the  size  of  the 
projectile  :  thus  bullets,  and  small  shell  and  bomb  fragments, 
make  perforations  or  scores  ;  larger  shell  fragments  cause  more 
ragged  wounds.  The  friable  nature  of  the  liver,  as  would  be 
supposed,  lends  itself  to  tearing  and  fragmentation  ;  thus 
there  may  be  radiating  fissures  from  a  central  hole,  crater-like 
exits,  or  pieces  nearly  or  completely  torn  off.  In  a  few  cases  a 
bullet  produces  the  most  extensive  destruction  (see  Fig.  9).  A 
case  mav  be  mentioned  in  which  the  whole  liver  was  shattered 


FIG.  19. — Vertical  wound  of  liver,  with  missile  in  situ. 

An  eleven-days-old  penetrating  shell-wound  of  the  liver.  The  point  of  entry  was  a  large  septic 
wound  on  the  right  anterior  axillary  fold.  The  thoracic  wall  was  penetrated  in  the  right  fourth 
interspace  in  the  mid-axillary  line,  with  slight  tearing  of  the  intercostal  muscles  and  of  the 
parietal  pleura,  but  with  no  rib  damage.  A  larg-e  hwmothorax  on  the  right  side  was  found  on  the 
sixth  day  heavily  infected  with  a  streptococcus. 

The  missile  lias  penetrated  the  right  lobe  of  the  liver,  and  is  lying  embedded  in,  and  partly  protruding 
from,  the  inferior  surface  of  the  organ.  The  centre  of  the  wound  track  was  filled  with  septic 
liquid  material,  heavily  bile-stained.  Outside  this  lies  a  zone  of  necrotic  liver,  the  necrosis  having 
supervened  on  infarction,  followed  by  sepsis.  This  is  separated  from  healthy  liver  by  a  well- 
developed  strong  capsule  of  inflammatory  fibrous  tissue,  (llrit.  Jouin.  of  Surgery.) 

by  a  rifle  bullet,  and  a  piece  4  inches  by  3  inches  lay  loose  in 
the  abdomen. 

The  track  or  torn  surface  is  at  first  ragged  and  bloody  ;  seen 
after  twelve  or  twenty-four  hours,  it  becomes  a  dirty  yellow- 
brown  ;  and  later  it  may  be  a  vivid  yellow  colour,  due  to 
bilious  staining. 

The  injury,  to  judge  from  microscopic  sections,  is  usually  limited 


102 


War  Surgery  of  the  Abdomen 


to  the  vicinity  of- the  wound  ;  and  in  those  cases  where  destruction 
of  cells  is  found  at  some  distance  from  the  wound  it  is  most 
probably  due  to  an  infarction  phenomenon  (Captain  J.  S.  Dunn). 
At  any  rate,  these  infarcted  areas  are  by  no  means  uncommon. 

The  gall-bladder  and  the  common  and  cystic  ducts  have  all 
been  wounded,  but  the  larger  bile-passages  do  not  seem  to  be  so 
often  wounded  as  one  might  expect. 

SYMPTOMS. — The  symptoms  are  often  slight,  and  one  has  no 
doubt  in  deciding  that  the  right  course  is  the  "  expectant  " 
one.  Sometimes  the  symptoms  seem  surprisingly  severe,  and  I 


Fio.  20. — Penetrating  wound  of  liver  caused  by  a  fragment  of  shell.    (Brit.  Journ. 

of  Surgery.) 

can  recall  two  cases  of  tangential  wounds  of  the  liver  which  could 
not  have  involved  the  liver  deeply,  and  in  which  there  was  no 
sign  of  blood  in  the  abdomen,  both  of  which  were  extremely 
shocked,  one  ending  fatally  ;  unfortunately,  there  was  no 
post-mortem.  In  two  other  unoperated  cases,  men  with  pulses 
of  160  recovered. 

There  are  the  usual  signs  of  abdominal  injury. 

Hcemorrhage. — This  is  not  altogether  commensurate  with 
the  size  of  the  wound,  and  its  amount  largely  depends  on 
whether  a  big  vein  has  been  opened  or  not;  if  not,  bleeding 
usually  ceases  spontaneously  in  from  six  to  ten  hours. 


Solid  Alimentary  Organs  and  Spleen        103 

Secondary  Haemorrhage.' — This  is  seen  at  the  base  as  a  rule. 
"  It  is  always  associated  with  sepsis.  The  advent  of  such 
haemorrhage  is  commonly  accompanied  by  pain,  distension  of 
the  belly,  rise  of  temperature,  and  acceleration  of  the  pulse, 
associated  with  pallor,  restlessness,  and  a  rapid  loss  of  strength. 
With  these  general  symptoms  a  localised  swelling  usually 
develops,  if  the  patient  survives  the  immediate  loss  of  blood, 
and  this  may  be  indistinguishable  from  a  secondary  abscess  " 
(Makins). 

Biliary  Function. — An  escape  of  bile  into  the  abdomen  is 
sometimes  met  with.  In  one  case  biliary  peritonitis  was  found 
at  the  primary  operation  and  ended  fatally  ;  no  hollow  viscus 
had  been  wounded.  Makins  mentions  one  case  in  which  a  col- 
lection of  bile  in  the  pelvis  required  operation  on  the  eighth  day  ; 
the  case  ended  fatally.  In  this  case  the  bile  came  from  the 
hepatic  duct.  Usually  the  bile  does  not  escape  from  the  torn 
liver  surface  to  any  extent  and  need  not  be  feared.  It  may, 
however,  stain  the  dressings  a  brilliant  yellow.  Bile  is  also 
met  with  in  the  pleura  in  abdomino-thoracic  wounds  without 
any  special  detriment  to  the  patient. 

Jaundice  of  a  slight  and  evanescent  character  is  seen  in  the 
first  few  days  after  wounding;  it  has  no  special  significance. 
Seen  later,  it  is  of  more  serious  import,  as  it  implies  sepsis. 
Makins  says*  :• — 

"  This  symptom  was  noted  as  an  early  sign  in  twelve  of  the 
thirty-seven  cases.  It  is  therefore  a  common  sign,  but  it  is 
variable  in  degree.  In  some  cases  it  is  early  and  deep,  in  others 
slight  and  evanescent,  and  it  is  usually  deepest  when  developing 
in  association  with  serious  septic  infection. 

"  The  fasces  retain  their  normal  colour,  and  deep  staining  of 
the  urine  is  rare.  Again,  in  fatal  cases  no  sign  of  gross  mechanical 
biliary  obstruction  is  met  with.  These  features  raise  the  question 
of  the  actual  nature  of  the  jaundice,  as  does  also  its  close 
resemblance  to  the  haemolytic  jaundice  often  accompanying  the 
gravest  forms  of  general  toxaemia.  It  is,  moreover,  often 
associated  with  a  considerable  degree  of  fever.  The  sign  is,  of 
course,  a  classical  one  in  the  course  of  any  case  of  rupture  of  the 

*  Brit.  Journ.  of  Surgery,  vol.  iii.,No.  12  (1916). 


IO4 


War  Surgery  of  the  Abdomen 


liver  substance,  whether  due  to  gunshot  injury  or  any  other 
cause,  and  in  all  it  is  probably  haemolytic  in  origin.  It  is  at 
any  rate  a  striking  fact  that,  in  the  obvious  absence  of  serious 
infection,  jaundice  is  either  very  slight,  or,  as  in  the  great 
majority  of  cases,  it  is  not  observed." 

TREATMENT. — Some  cases  require  no  operation,  as  there  are 
obviously  no  other  organs  wounded,  and  the  patient's  condition 
is  good.  Many  cases  are  operated  on  solely  because  of  the 
possibility  of  injury  to  other  organs.  If  such  injuries  could  be 
excluded,  I  am  inclined  to  think  that  the  best  results  would  be 
obtained  by  non-interference  in  the  great  majority  of  cases. 
When,  however,  the  projectile  is  a  large  one,  it  should  be 
removed  if  at  all  accessible.  If  the  projectile  has  entered 
through  the  thorax  and  lodged  in  the  liver  the  transpleural 
route  will  be  the  best ;  it  is  possible  to  deal  with  both  the  pleural 
and  liver  injury.  If  the  abdomen  has  been  traversed  the  case 
is  not  so  clear,  and  most  probably  the  standard  paramedian 
incision  is  best  in  the  first  instance.  A  subcostal  incision  may 
at  times  be  useful.  As  to  the  treatment  of  the  liver  itself,  it 
is  often  unnecessary  to  do  anything.  In  other  cases  packing  is 
required  ;  suture  has  not  proved  very  satisfactory.  Ragged 
edges  may  be  trimmed  and  any  semi-detached  portions  of 
tissue  removed.  The  big  bile-passages  can  be  dealt  with  on 
ordinary  lines  by  suture  and  drainage. 

MORTALITY  AND  CAUSES  OF  DEATH  :— 

TABLE  XX. — To  show  Mortality  of  Liver  Wounds. 


Treatment. 

To  Base. 

Died. 

Not  known. 

Operation,  complicated 

14 

26 

4 

,,           uncomplicated 

72 

32 

— 

No  operation  (no  indication)   .  . 

23 

— 

The  mortality  of  the  uncomplicated  wounds  is  therefore  29'18 
per  cent. 

The  causes  of  death  at  the  front  may  be  seen  in  the  follow- 
ing list,  which  shows  the  clinical  cause  of  death  in  a  series 
of  consecutive  cases  :  jaundice  and  sepsis,  1  ;  shock  and 


Solid  Alimentary  Organs  and  Spleen        105 

haemorrhage,  9  ;  "  biliary  "  peritonitis,  1  ;  lung  trouble,  4  ;  gas 
gangrene,  1. 

Speaking  of  causes  of  death  at  the  Base  Makins  says  that  in 
twenty-five  cases  in  which  a  liver  wound  was  the  principal 
cause  of  death  60  per  cent,  of  the  cases  died  of  sepsis  and 
40  per  cent,  of  secondary  haemorrhage.  Death  in  a  certain 
number  was  also  in  part  due  to  infection  of  the  pleura. 

In  uncomplicated  wounds,  the  mortality  has  a  distinct  relation 
with  the  amount  of  injury,  both  because  of  the  quantity  of 
blood  lost  and  on  account  of  the  amount  of  injured  substance. 
No  connection  has  been  traced  between  the  direction  of  the 
projectile  and  the  fatality  ;  side-to-side  lesions  were  said  to  be 
commoner  at  the  Base.  Injuries  of  the  big  bile-passages  do 
not  seem  to  increase^ the  gravity  to  any  appreciable  extent. 

Pancreas. 

FREQUENCY. — In  965  operated  cases,  the  pancreas  was 
wounded  5  times.  Very  few  of  such  injuries  have  been  noted. 
Possibly  many  are  missed,  and  diagnosed  as  retroperitoneal 
haematoma.  In  addition,  many  may  be  rapidly  fatal ;  the 
association  of  the  gland  with  the  big  vessels  need  hardly  be 
mentioned. 

ASSOCIATED  IN  JURIES. — The  organ  was  found  wounded  three 
times  with  other  viscera — namely,  stomach,  stomach  and  liver, 
and  stomach  and  kidney.  All  three  were  fatal.  It  was  wounded 
alone  on  two  occasions,  one  of  which  went  to  the  Base  without 
symptoms. 

SYMPTOMS. — There  are  no  distinctive  symptoms  ;  the  lesions 
are  found  at  explorations,  and  are  sometimes  accompanied  by 
fat  necrosis. 

PROGNOSIS. — One  case  was  sent  to  the  Base  in  which  the 
pancreas  was  obviously  perforated  by  a  bullet ;  the  other  cases 
were  fatal. 

Makins  has  published  some  cases  of  wounds  of  this  organ 
which  he  has  seen  at  the  Base.  He  says  that  they  were  dis- 
covered during  the  performance  of  operations  for  intestinal 
injuries,  and  that  the  typical  results  of  the  escape  of  the  pan- 
creatic juice  have  been  observed.  They  have  usually  proved 


io6 


War  Surgery  of  the  Abdomen 


fatal.  He  mentions  one  interesting  case  in  which  an  abscess 
formed  and  was  opened,  in  which  the  patient  eventually 
recovered  and  was  discharged  to  England.  The  man  walked 
six  miles  after  his  wound.  He  had  been  detained  at  a  Casualty 
Clearing  Station  on  suspicion  of  an  injury  to  the  alimentary 
tract. 

Spleen. 

FREQUENCY. — In  965  abdominal  operations,  the  spleen  was 
found  wounded  54  times.  In  32  instances  it  was  the  only  organ 
damaged. 

ASSOCIATED  INJURIES  :•— 

TABLE  XXI. — Showing  the  Complicating  Injuries  of  the  Spleen. 


Other  Viscera  wounded. 

To  Base. 

Died. 

Stomach 

1 

3 

„        and  colon 

— 

1 

Small  gut     .  . 

— 

1 

,,        and  colon 

— 

1 

„    kidney 

1 

— 

Colon 

— 

3 

,,     and  kidney 

— 

2 

Kidney 

7 

•> 

NATURE  OF  IN  JURIES. — These  consist  of  perforations,  tears, 
slits  in  the  capsule,  avulsion  of  poles,  hemisection,  division  of 
pedicle,  and  almost  complete  disruption. 

SYMPTOMS. — The  symptoms  are  mainly  those  of  haemorrhage, 
and  the  diagnosis  is  made  on  these  and  on  the  position  of  the 
wound.  Very  often  the  organ  is  only  found  wounded  in  the 
course  of  an  exploratory  operation.  There  is  nothing  special 
about  the  haemorrhage,  and  the  damming  up  of  blood  in  the  left 
loin,  which  has  been  said  to  be  a  feature  of  this  injury  in  civil 
practice,  has  not  been  conspicuous  in  the  present  campaign. 
The  amount  of  haemorrhage  varies  very  much,  and  depends 
mainly  upon  whether  the  vessels  are  injured.  The  splenic 
pulp  has  been  found  bleeding  forty-eight  hours  after  injury, 
but  usually  ceases  after  ten  hours. 


Solid  Alimentary  Organs  and   Spleen       107 
TREATMENT : — 

TABLE  XXII. — To  show  Treatment  of  Splenic  Wounds. 


Association  with  other  Wounds. 

Packed,  sutured,  or 
left  alone. 

Excised. 

To  Base. 

Died. 

To  Base. 

Died. 

With  other  organs 
Spleen  alone  wounded 

6 
12 

8 
4 

3 

4 

5 
12 

Total 

18 

12 

7 

17 

There  were  five  cases  in  which  the  spleen  and  kidney  were  both 
excised  ;    two  of  these  were  fatal.     The  other  three  fatal  cases  of 
excision  in  complicated  wounds  were  instances  of  wounds  of  stomach  • 
and  spleen  (1),  and  colon  and  spleen  (2). 

The  spleen  is  often  found  wounded  after  the  standard  para- 
median  exploration,  and  can  be  dealt  with  through  this,  though 
not  very  conveniently.  A  rectus  sheath  incision  with  a  trans- 
verse extension  or  a  subcostal  one  are  perhaps  more  convenient. 

If  associated  with  a  thoracic  wound  which  requires  attention, 
it  can  be  dealt  with  through  the  diaphragm  by  extending  the 
rib  incision  to  or  through  the  costal  margin.  If,  however,  the 
missile  has  passed  across  the  abdomen,  this  incision  will  not 
suffice,  though  the  cardiac  part  of  the  stomach  and  the 
splenic  flexure  of  the  colon  can  be  dealt  with.  As  a  matter  of 
fact,  the  association  of  splenic  and  gastric  injuries  is  not 
common. 

If  the  haemorrhage  has  ceased,  the  organ  is  best  left  alone. 
Suturing  or  packing  will  control  the  haemorrhage  if  this  is  going 
on.  As  a  matter  of  fact,  sutured  holes  are  apt  to  bleed  almost 
as  much  as  a  raw  surface,  unless  the  haemorrhage  is  fairly  free. 
Excision  should  only  be  resorted  to  if  the  organ  is  badly  injured 
or  the  vessels  are  torn. 

One  point  has  to  be  borne  in  mind  in  operating  on  these  cases, 
especially  if  associated  with  wounds  of  the  kidney  vessels.  The 


io8 


War  Surgery  of  the  Abdomen 


haemorrhage,  which  very  likely  has  been  controlled  or  diminished 
by  the  clotting,  is  likely  to  restart  in  an  alarming  manner 
directly  the  clot  is  disturbed.  It  is  therefore  absolutely  neces- 
sary to  have  everything  ready  for  the  arrest  of  haemorrhage. 


Fia.  21. —  Bullet  wound  of  spleen.  The  organ  was  almost  completely  divided.  The 
vessels  ruptured  in  the  hilum.  Under  care  of  Captain  Owen  Richards.  (Brit. 
Journ.  of  Surgery  and  Medical  Society  of  London.) 

MORTALITY  AND  CAUSES  OF  DEATH. — Shock  and  haemorrhage 
are  the  main  causes  of  death.  The  mortality  in  uncomplicated 
cases  was  50  per  cent.  One  curious  case  may  be  quoted,  that 
of  a  simple  perforation  of  the  spleen,  where  death  occurred 
suddenly  without  cause  on  the  fifth  day. 


CHAPTER   VII. 

GENITOURINARY  ORGANS. 

Kidney. 

FREQUENCY. — This  organ  was  wounded  73  times  in  965 
abdominal  injuries.  It  was  the  only  viscus  wounded  in  37 
instances. 

ASSOCIATED  INJURIES. — The  following  table  shows  the 
number  of  times  each  complicating  organ  was  hit  :— 

TABLE  XXIII. — Kidney  Wounds  complicated  with  Wounds  of 

other  Organs. 


Other  Viscera  wounded. 

To  Base. 

Died. 

Result  not 
known. 

Stomach 

1 

3 

Small  gut 

4 

3 

— 

Colon 

3 

4 

— 

Pancreas 

.  —  . 

1 

— 

Liver 

3 

9 

2 

Spleen 

8 

4 

•  —  • 

NATURE  OF  LESIONS. — In  two  cases  both  kidneys  were  hit  by 
the  same  missile.  Both  were  fatal  ;  one  had  paraplegia.  The 
nature  of  the  projectile  has  no  particular  effect  on  the  injury. 
As  is  the  case  with  other  solid  organs,  the  kidney  is  liable  to 
extensive  rupture.  The  actual  lesions  may  be  perforations, 
scores,  furrows,  cracks  in  the  capsule,  avulsion  or  pulping  of 
the  poles,  hemisection,  and  almost  complete  disruption. 

Sometimes  the  kidney  is  found  lying  loose,  the  pedicle  having 
been  ruptured  ;  sometimes  the  pelvis  is  alone  perforated  ;  at 
other  times  the  vessels  are  completely  divided,  the  ureter  remain- 
ing intact.  The  amount  of  haemorrhage  depends  upon  whether 
a  vessel  has  been  injured  or  not  ;  there  is  very  often  a  consider- 


no  War  Surgery  of  the  Abdomen 

able    perinephric    haematoma.      In    contradistinction    to    civil 
injuries,  intraperitoneal  haemorrhage  is  very  frequent. 

Microscopic  examination  shows  that  the  destruction  of 
kidney  cells  is  limited  to  the  immediate  vicinity  of  the  wound 
or  of  the  fissures  that  extend  from  it.  Infarction  phenomena 
are  not  rare  (see  Fig.  23),  and  in  some  instances  considerable 
portions  of  the  kidney  necrose  if  the  artery  supplying  such 
part  is  divided  outside  the  organ.  The  reader  is  referred  to 


FIG.  22. — Bullet  wound  of  the  kidney. 

The  small  aperture  of  entry  is  seen  in  the  inset.  The  larger  exit  wound  at  the 
opposite  surface  exhibits  well  the  protrusion  of  the  renal  tissue  and  a  moderate 
degree  of  destruction.  The  lacerated  capsule  has  receded  some  distance  on  the 
surface  of  the  organ.  (Brit.  Journ.  of  Surgery.) 

papers  on  these  subjects  by  Captain  Bashford  and  Colonel  A. 
Fullerton.* 

SYMPTOMS. — The  shock  is  not  as  a  rule  very  great,  and 
depends  largely  on  the  amount  of  blood  lost  ;  this,  perhaps,  is 
peculiar,  when  one  remembers  the  effect  produced  by  the  kidney 
blow  in  boxing.  On  the  other  hand,  one  sees  cases  of  kidney 
injury  which  recover  without  operation,  in  which  the  pulse 

*  Brit.  Journ.  of  Surgery,  vol.  iv.,  No.  15,  and  vol.  v.,  No.  18. 


Genito-urinary  Organs  1 1 1 

may  be  as  high  as  140  and  the  shock  extreme.  The  dulness  due 
to  free  fluid  in  the  abdomen  is  more  common  than  in  civil 
injuries,  and  manifests  itself  in  the  right  or  left  side  according 
to  the  organ  injured. 

Hcematuria.- — This  is  usually  present,  but  it  may  not  occur  at 
once.  The  absence  of  this  sign  is  due  either  to  suppression,  or 
to  the  presence  of  clots  or  pieces  of  kidney  in  the  ureter.  Profuse 


FIG.  23. — Oblique  perforation    of  the    kidney  caused  by  a   bullet.     The  glass  rod 
projects  from  the  exit  aperture.     (Brit.  Journ.  of  Surgery.) 

haemorrhage  into  the  bladder  is  not  common  in  the  early  stages. 
Haematuria  usually  clears  up  in  a  few  days,  but  may  persist. 

Extravasation  of  Urine. — This  is  not  usually  marked,  and  is 
most  probably  limited  to  those  cases  in  which  the  pelvis  is 
involved. 

Gas  Infection. — This  has  occurred  in  the  perinephric  haema- 
toma  in  a  certain  number  of  cases. 

Excretion  of  Urine. — The  escape  of  urine  through  the  loin 
wound  is  often  delayed.  This  may  be  due,  like  the  absence  of 
haematuria,  to  suppression,  or  blocking  of  the  duct.  In  two 


U2  War  Surgery  of  the  Abdomen 

cases  of  double  wound  no  urine  was  passed  into  the  bladder, 
though  it  is  doubtful  whether  there  was  not  some  from  the  loin 
wounds.  Anyhow  the  double  wound  seriously  interfered  with 
this  function.  It  is  possible,  therefore,  that  if  only  one  kidney  is 
wounded,  it  ceases  secreting. 

I  asked  Captain  Sampson,  who  had  a  rather  extensive 
experience  with  these  injuries,  to  measure  the  urine  after  the 
excision  of  the  kidney  ;  the  amount  was  about  25  oz.  in  the  day. 


FIG.  24. — Bullet  wound  of  the  right  kidney.  This  has  practically  bisected  the 
organ,  extending  into  the  renal  pelvis.  Haematuria  was  a  marked  feature  of 
the  symptoms.  (Brit.  Journ.  of  Surgery.) 

The  patients  were  not  thirsty,  and  did  not  demand  water  ;  but 
if  they  were  put  on  a  forced  hydropathy,  the  remaining  kidney 
at  once  responded,  and  passed  up  to  80  or  90  oz. 

SECONDARY  COMPLICATIONS. — A  secondary  haemorrhage  is  a 
fairly  frequent,  and  often  fatal,  late  complication.  It  occurs 
most  often  during  the  second  and  third  weeks  after  injury. 
The  urine  is  generally  contaminated.  Secondary  haemorrhage 
may  start  afresh,  or  it  may  manifest  itself  as  an  exacerbation 


Genitourinary  Organs  113 

of  a  persistent  primary  haemorrhage.  Unlike  primary  haemor- 
rhage, it  is  often  accompanied  with  clotting  of  the  blood  in  the 
bladder. 

An  interesting   case   reported  by  Makins  *  may  be  quoted 
here  :— 

"  Case  2. — (Under  the  care  of  Captain  Buxton.) 
"A  man  was  wounded  by  a  bullet  which  entered  just  below  the 
right  costal  margin  in  the  nipple  line,  and  emerged  below  the 


FIG.  25. — Comminution  of  the  upper  half  of  the  kidney.  The  organ  has  been 
reconstructed  by  assembling  a  number  of  fragments  enclosed  in  blood  clot. 
(Brit.  Journ.  of  Surgery.) 

twelfth  rib  behind.  Primary  haematuria  followed,  and  con- 
tinued, except  for  one  day's  interval,  until  the  patient's  arrival 
at  the  General  Hospital  on  the  eighth  day.  Some  dysuria  from 
the  presence  of  blood  clot  in  the  bladder  had  necessitated 
occasional  catheterisation. 

"On  the  ninth  day  the  patient's  general  condition  was  good; 
he  looked  sallow,  but  the  pulse  was  of  fair  strength  and  not 
rapid.  The  haematuria  and  dysuria  persisted,  and  on  this  and 

*  Brit.  Journ.  of  Surgery,  vol.  iii.,  No.  12  (1910). 


114  War  Surgery  of  the  Abdomen 

the  following  day  90  ounces  of  urine  and  blood  were  voided, 
the  urine  containing  streptococci. 

"On  the  twelfth  day,  as  no  improvement  had  taken  place,  a 
type  right  lumbar  nephrectomy  was  performed.  The  perirenal 
tissues  were  infiltrated  with  blood  and  some  urine,  but  no 
extensive  extravasation  of  urine  had  occurred.  The  bladder  was 
full  of  blood  clot,  which  was  removed  with  a  lithotrity  evacuator. 


Fiu.  26. — Minimal  injury  to  the  right  kidney  accompanying  a  retroperitoneal  per- 
foration of  the  duodenum.  A  second  exactly  similar  injury  was  also  met  with. 
In  neither  case  was  any  sign  of  the  renal  lesion  observed,  and  in  both  the  injured 
duodenum  contracted  adhesions  to  the  groove  in  the  kidney.  (Brit.  Journ.  of 
Surgery. ) 

The  kidney  was  practically  bisected,  and  was  large,  probably 
partly  as  a  result  of  infection. 

"For  the  next  three  days  seven  pints  of  urine  were  voided 
daily,  the  quantity  then  decreasing  until  the  normal  was  reached 
on  the  seventh  day. 

"  The  patient  meanwhile  was  ill  from  the  streptococcic  infec- 
tion, and  made  a  very  slow  recovery." 

TREATMENT.- — The  method  of  treatment  adopted  in  the  cases 
enumerated  under  "  Kidney  explored  "  (Table  XXIV.)  was 
packing,  suture,  or  nothing,  the  actual  procedure  depending  on 


Genito-urinary  Organs 


whether  the  organ  was  bleeding  or  not.  A  loin  drain  was  used  in 
many  cases.  In  a  large  number  of  instances  it  is  probable  that 
the  cases  would  have  recovered  without  operation,  which  had 
to  be  undertaken  to  exclude  other  injury.  Nephrectomy  should 
be  reserved  for  those  cases  in  which  the  vessels  are  torn  or  the 
organ  is  greatly  shattered.  If  a  pole  is  shattered  a  local 
trimming  of  the  devitalised  tissue  is  worthy  of  trial. 

If  the  kidney  is  probably  the  only  organ  wounded,  or  if  the 
missile  track  only  crosses  one  side  of  the  abdomen  in  a  horizontal 
direction,  the  transverse  incision  is  the  best. 

TABLE   XXIV. — Table  of  Operations   to    show   Treatment  and 

Results. 


Operation. 

To  Base. 

Died. 

Kidney  explored  * 

25 

7 

Nephrectomy  (uncomplicated) 

2 

3 

(spleen  wounded) 

3 

— 

(liver  wounded) 

1 

1 

(bladder  wounded) 

— 

1 

(colon  wounded) 

— 

1 

and   splenectomy 

3 

2 

*  In  these  cases  the  kidney  was  considered  the  principal  wound,  and 
so  the  operation  is  entered  under  this  head  ;  the  kidney  was  found 
wounded  in  many  other  cases  in  the  course  of  an  abdominal  explora- 
tion, but  these  cases  arc  not  shown  in  this  table.  The  organ  was 
wounded  seventy-three  times,  and  the  difference  between  this  number 
and  the  number  (forty-nine)  shown  in  this  table  represents  the  number 
of  times  that  the  kidney  wound  was  a  secondary  consideration. 

As  was  stated  in  speaking  of  splenic  injuries,  the  haemorrhage 
from  wounded  kidney  vessels  is  very  liable  to  restart  with 
alarming  rapidity  directly  the  clots  are  disturbed.  It  is  rather 
interesting  here  to  mention  that  the  number  of  kidney  wounds 
treated  at  an  advanced  operating  centre  seems  -to  be  larger  than 
in  the  Casualty  Clearing  Station.  This  is  most  probably  due  to 
the  fact  that  the  cases  arriving  earlier  have  not  suffered  so  much 
from  haemorrhage. 

MORTALITY  AND  CAUSES  OF  DEATH. — In  thirty-seven  uncom- 

8—2 


ii6  War  Surgery  of  the  Abdomen 


plicated  cases,  there  were  ten  deaths.  Shock  and  haemorrhage 
are  by  far  the  most  common  causes  at  the  Front.  Associated 
wounds  of  the  liver  and  kidney  seem  to  constitute  a  very 
dangerous  combination.  At  the  Base,  secondary  haemorrhage 
and  sepsis  play  the  chief  part  in  the  fatal  result. 

Ureter. 

The  ureter  is  not  very  frequently  injured,  but  the  cases  have 
done  well.  The  injury  was  found  in  the  course  of  an  exploratory 
coeliotomy.  Suture  or  drainage  formed  the  methods  of  treatment. 

Colonel  Andrew  Fullerton,  speaking  of  the  experience  at  the 
Base,  says  that  the  urinary  fistulae  resulting  from  wounds  of  the 
ureter  heal  well  if  left  alone. 

Bladder. 

FREQUENCY. — This  organ  was  perforated  forty-five  times  in 
965  operated  cases.  In  twenty-five  instances  it  was  the  only 
organ  injured. 

ASSOCIATED  INJURIES. — The  small  intestine  is  the  organ 
most  frequently  wounded  in  association.  It  is  remarkable  how 
seldom  the  pelvic  colon  or  rectum  is  perforated  at  the  same  time. 
The  pelvis  is  fractured  in  a  large  proportion  of  cases. 

TABLE  XXV.— Table  of  Bladder  Wounds. 


Association  with  other  Wounds. 

To  Base. 

Died. 

Result  not 
known. 

Small  gut  (resection),  intraperitoneal  .  . 



5 

_ 

,,        (suture),  one  extraperitoneal 

1 

6 

— 

,,        (resection),  colon  anus 

— 

1 

—  - 

,,         •     „             rectum  (suture) 

— 

1 

— 

Colon*    

— 

2 

1 

Rectum,  extraperitoneal 

— 

1 

— 

.    .        ,  f  extraperitoneal 
Bladder  alone  mjured^^^^ 

9 
2 

11 
3 

— 

Total        

12 

30 

1 

*  Transverse  colon,  1  ;   pelvic  colon,  1  ;   wound  of  bladder  extra- 
peritoneal,  1. 


Genito-urinary  Organs  117 

NATURE  OF  IN  JURIES. — These  may  be  either  intraperitoneal 
or  extraperitoneal,  or  both.  The  intraperitoneal  lesions — 
perforations,  tears,  or  slits — are  very  often  not  extensive.  The 
extraperitoneal  wounds,  often  accompanied  by  much  haematoma, 
are  slits  or  tears.  They  are  usually  situated  at  the  sides  of  the 
bladder,  and  are  often  caused  by  bony  spicules.  There  is  only 
one  instance  in  this  series  where  the  rectal  surface  was  wounded. 
It  is  also  remarkable  how  few  have  been  the  observed  cases  of 
prostatic  wounds,  so  few  that  there  is  really  nothing  to  be 
said  about  them.  The  combined  intraperitoneal  and  extra- 
peritoneal  injuries  are  usually  caused  by  oblique  wounds,  the 
missiles  entering  by  the  lower  lateral  part  of  the  bladder  and 
passing  out  through  the  peritoneal  surface.  Projectiles  some- 
times lodge  within  the  bladder,  and  cause  pain  at  a  later  period. 
Bone  spicules  have  also  been  formed  in  the  viscus.  One  interest- 
ing case  was  under  the  care  of  Captain  Luker  in  which  a  pro- 
jectile, passing  in  by  the  buttock,  wounded  the  postero- 
external  angle.  It  pushed  a  piece  of  cloth  into  the  viscus  and 
then  passed  on  and  lodged  behind  the  pubis. 

SYMPTOMS. — These  are  not  of  great  importance,  as  most  cases 
are  submitted  to  operation  on  principle.  Intraperitoneal  wounds 
are  found  in  the  case  of  an  abdominal  exploration.  The 
extraperitoneal  wounds  may  be  accompanied  by  obvious  swelling 
above  Poupart's  ligament,  but  this  sign  may  be  absent. 

There  may  be  haematuria,  or  micturition  may  be  impossible. 
Haematuria  also  occurs  with  bruising  of  the  bladder  without 
penetration.  The  cystoscope  has  not  been  used,  and  perhaps 
would  not  be  of  much  use  in  the  intraperitoneal  wounds,  as  the 
bladder  cannot  be  distended. 

Vomiting  is  not  an  infrequent  symptom  in  extraperitoneal 
wounds,  and  has  occurred  in  simple  extravesical  haematoma. 
It  is  of  no  great  value  as  a  symptom.  Extraperitoneal  wounds 
are  often  accompanied  with  severe  constitutional  disturbance, 
the  pulse  mounting  to  120.  This  phenomenon  is  apparently 
septic  in  origin. 

TREATMENT. — Intraperitoneal  Wounds.- — These  are,  as  a  rule, 
easily  sutured,  except  those  which  occur  at  the  very  bottom  of 
Douglas'  pouch.  The  bladder  should  be  explored  for  a  foreign 


n8  War  Surgery  of  the  Abdomen 

body.  Suprapubic  drainage  is  not  necessary  here.  Catheterisa- 
tion  for  a  few  days  may  be  necessary,  or  a  catheter  may  be 
tied  in,  though  this  treatment  is  not  to  be  continued  for  long, 
and  is  not  favoured  by  some. 

Extraperitoneal  Wounds. — These  are  treated  by  an  incision 
down  to  the  wound  in  the  bladder,  which  latter  may  be  sutured 
if  possible,  and  a  drain  left  in  the  space  formed  by  the  operation. 
If  the  wound  in  the  bladder  cannot  be  sutured,  it  is  most 
probable  that  a  drain  down  to  the  wound  will  be  sufficient ; 
if  there  is  any  doubt,  a  drain  into  the  bladder  through  the 
wound  is  probably  the  safest  course.  It  occasionally  happens 
that  one  meets  with  urinary  extravasation  in  an  extravesical 
haematoma  and  cannot  find  the  hole  into  the  viscus.  Under 
these  conditions  it  is  somewhat  doubtful  whether  the  right 
course  is  to  be  content  with  an  extravesical  drain  or  to  do  a 
suprapubic  cystostomy  in  addition.  I  am  rather  inclined 
myself  to  advocate  the  latter,  as  I  have  seen  bad  results  follow 
such  extravasation. 

In  those  cases  where  the  bladder  is  wounded  on  the  rectal 
surface  it  would  appear  well  to  open  the  bladder  and  suture  the 
rent  from  the  inside,  as  has  been  done  by  Captain  Hamilton 
Drummond. 

MORTALITY  AND  CAUSES  OF  DEATH. — The  uncomplicated 
bladder  wounds  show  a  mortality  of  56  per  cent.,  fourteen 
deaths  in  twenty-five  cases.  Shock  and  haemorrhage  form  the 
causes  in  the  majority.  Fracture  of  the  pelvis  seems  to  greatly 
increas  the  shock,  and  wounds  of  the  pelvic  veins  are  respon- 
sible for  a  great  deal  of  the  haemorrhage. 

In  the  case  of  complicating  small-gut  injuries,  the  picture  is 
dismal  in  the  extreme.  There  were  sixteen  instances  with  only 
one  recovery.  Most  of  these  cases  are  intraperitoneal  wounds, 
which  in  civil  practice,  and  uncomplicated,  are  not  greatly 
feared.  It  would  appear  that  the  increase  in  time  necessary 
to  repair  the  bladder,  after  other  serious  injuries  have  been  dealt 
with,  was  able  to  turn  the  balance  against  the  patient,  for  the 
mortality  is  much  worse  than  in  intestinal  injuries  alone. 


CHAPTER   VIII. 

ABDOMINO-THORACIC    WOUNDS  AND  DIAPHRAGMATIC  HERNIA. 
Abdomino-thoracic  Wounds. 

A  GOOD  deal  has  been  written  about  these  wounds,  and  there 
is  perhaps  an  inclination  to  regard  them  as  a  type  apart  and 
as  possessing  peculiar  properties.  It  has  been  shown  that  the 
mortality  of  wounds  increases  in  proportion  to  their  multipli- 
city ;  it  is  not  therefore  to  be  wondered  at  that  abdomino- 
thoracic  wounds  should  have  a  heavier  mortality  than  either 
chest  or  abdominal  wounds  alone.  It  will  be  seen  later  on  that 
in  a  series  of  cases  the  total  operative  abdominal  mortality 
(excluding  abdomino-thoracic  wounds)  was  49  per  cent.,  while 
that  of  abdomino-thoracic  wounds  was  55 '5  per  cent.  This  is 
not  such  a  large  increase  when  it  is  remembered  that  chest 
wounds  within  the  period  before  evacuation  to  the  Base  produce 
a  mortality  of  about  22  per  cent,  in  themselves.  Another  point 
to  be  borne  in  mind  in  considering  the  increased  mortality 
supposedly  due  to  the  thoracic  complication  is  that  such 
thoracic  wounds  are  accompanied  by  wounds  in  a  region  of  the 
abdomen  that  has  been  shown  (see  Fig.  4)  to  be  especially 
dangerous  to  life. 

Frequency. — In  839  cases  of  abdominal  wounds  there  were 
101  cases  in  which  the  missile  penetrated  the  thoracic  in  addition 
to  the  abdominal  cavity.  The  percentage  of  wounds  involving 
both  cavities  is  therefore  about  12  per  cent.  If  only  operated 
cases  are  taken  into  account  the  ratio  is  550  to  70,  or,  again, 
about  12  per  cent. 

Side. — These  wounds  are  mostly  confined  to  one  side  of  the 
diaphragm,  though  the  opposite  chest  may  be  involved.  Wounds 
low  enough  to  involve  both  sides  of  the  diaphragm  have 
usually  been  fatal,  though  some  reach  hospital.  In  this  series 
both  sides  are  equally  affected  and  show  an  equal  mortality. 


i2o          War  Surgery  of  the  Abdomen 

Nature  of  Projectiles. — As   in  all  abdominal   wounds,    shell 
fragments  are  the  most  frequent  causal  agents. 

TABLE  XXVT. 


Tn  T?acf» 

THoH 

Bullet  

2 

8 

High-explosive  fragments 

23 

47 

Shrapnel  ball 

5 

4 

Grenade 

2 

1 

Aerial  bomb 

— 

1 

Bayonet           .  .          .  .          .  .          .  . 

2 

1 

Diaphragmatic  Lesions.  —  These  are  mostly  found  on  the  sloping 
muscular  portion.  A  large  proportion  involve  only  that  part 
which  is  in  contact  with  the  thoracic  wall.  The  following 
figures,  taken  in  a  consecutive  series  of  cases,  show  the  extent 
and  form  of  the  rent  as  described  by  the  operator  :— 


Linear  tear  (in  inches),  3,  1J,  1,  1J,  1,  1,  1,  •£,  ^,  1, 


•, 


Irregular  hole,  size  of,  5s.,  Is.,  Qd.,  2s.  6d.,  2s.  Qd.  ;  (in  inches), 
1£,  2  x  1,  2J  x  1,  2,  |,  1,  1£,  f,  small,  small. 

Puncture,  described  thus  in  ten  cases. 

The  nature  and  extent  of  the  lesion  depend  on  the  size  of  the 
missile  and  on  its  inclination  to  the  plane  of  the  diaphragm  at 
the  point  of  impact.  Small  missiles  may  make  large  tears  if 
their  course  lies  in  the  plane  of  the  organ.  Fractured  ribs  are 
also  responsible  for  a  certain  amount  of  damage. 

Organs  herniated.  —  In  a  certain  number  of  cases  on  the  left 
side  some  of  the  abdominal  viscera  pass  through  the  gaps. 
There  was  herniation  in  eight  cases  in  the  above  series,  which 
were  mostly  explored  in  the  first  instance  through  the  abdomen. 
According  to  some  observers,  this  number  of  herniations  is 
below  the  average.  The  omentum  is  the  organ  most  often 
involved,  and  the  first  part  to  pass  through  is  the  left  side  or  the 
gastro-splenic  fold.  It  nearly  always  accompanies  other  organs 
when  they  are  protruded.  In  one  unoperated  case  that  died 
from  other  injuries  about  a  week  after  wounding,  the  omentum 
protruded  through  the  rent,  effectually  plugging  it,  and  formed 


Abdomino-thoracic  Wounds 


121 


the  same  granular-looking,  mushroom-like  button  that  one  used 
to  see  on  the  abdominal  wall  in  the  preoperative  days.  As  in 
other  cases,  it  is  both  carried  out  or  expelled  by  abdominal 
pressure.  The  spleen,  stomach,  and  left  part  of  the  transverse 
colon  are  the  organs  next  most  frequently  herniated.  The 
following  combinations  occur  :  stomach  and  spleen  ;  stomach 
and  transverse  colon  ;  stomach,  transverse  colon,  and  small 
gut.  The  stomach  does  not  in  the  early  stage  pass  through 
unless  the  rent  is  of  considerable  size,  but  is  at  a  later  period 
herniated  through  a  comparatively  small  rent. 

Abdominal  Organs  wounded. — This  is  an  important  subject 
because,  as  will  be  pointed  out  later,  it  has  a  direct  bearing  on 
the  treatment  to  be  adopted  and  the  route  employed.  Hollow 
viscera  were  wounded  28  times  in  70  cases. 

TABLE    XXVII. — To    show    Abdominal    Viscera    wounded    in 
Abdomino-thoracic  Injuries. 


Organ  wounded. 

To  Base. 

Died. 

Stomach 

4 

and  liver 

1 

1 

,,    spleen 

— 

2 

,,    transverse  colon 

-  — 

1 

,,    jejunum  and  spleen   .  . 

•  — 

1 

„    kidney              

1 

— 

Jejunum 

1 

1 

and  liver 

— 

1 

„    kidney              

—  • 

1 

,,    spleen  and  colon 

— 

1 

,,    transverse  colon 

-  —  . 

2 

Colon 

3 

1 

,,     and  spleen 

— 

2 

»     liver           

1 

2 

,,        ,,        ,,    and  oesophagus 

— 

1 

Liver 

10 

7 

,,     and  kidney 

3 

3 

Kidney.  . 

2 

1 

Spleen  .  . 

G 

5 

.,    and  kidney 

1 

Pancreas  and  splenic  vein 

— 

1 

No  viscus 

3 

— 

Total     

31 

39 

122  War  Surgery  of  the  Abdomen 

TABLE  XXVIII.— To  show   the   Number  of  Times  Individual 
Organs  were  wounded. 


Organ. 

Frequency. 

Liver 

30 

Spleen 
Colon 

18 
18 

Kidney     .  .          .  . 
Stomach 

13 
11 

Jejunum 
(Esophagus 
Pancreas 

0 
1 
1 

No  viscus 

3 

TABLE   XXIX. — To  show  Influence  of  a   Wound  of  a  Hollow 
Viscus  on  the  Mortality. 


— 

Base. 

Died. 

Hollow  viscera  wounded 
No  hollow  viscera  wounded 

7 
21 

21 

18 

Total     

31 

39 

TREATMENT. — In  all  cases  it  is  very  necessary  to  know  the 
track  of  the  projectile  and  where  it  has  lodged.  If  the  wound 
only  involves  the  neighbourhood  of  the  diaphragm  there  is  no 
need  for  a  complete  abdominal  exploration.  A  transpleural 
incision  will  here  allow  of  repair  to  the  thoracic  region,  and  an 
extension  of  it  will  very  likely  be  a  convenient  way  of  treating 
the  abdominal  viscera.  If  the  projectile  has  passed  farther 
afield  it  is  obvious  that  an  enlargement  of  the  transpleural 
incision  will  not  suffice,  and  that  a  separate  coeliotomy  will  be 
necessary.  It  is  in  these  cases  that  one  has  to  determine  whether 
the  thoracic  wound  requires  operative  treatment  and,  if  it  does, 
whether  preference  should  be  given  to  it  or  the  abdominal 
wound. 

In  making  up  one's  mind  certain  facts  have  to  be  considered. 


Abdomino-thoracic  Wounds  123 

(1)  It  has   been  shown  that  the  mortality  is   still  largely 
dependent  on  the  abdominal  injury.     (Table  XXIX.) 

(2)  The  chief  indications  for  immediate  operative  treatment 
of  a  thoracic  wound  that  have  been  advanced  are  as  follows  : 
(a)  an  open  "  blowing  wound  "  ;    (6)  a  "  stove-in  "  chest  wall ; 
(c)  the  retention  in  the  thorax  of  a  large  missile  ;   (d)  a  wound 
of  the  diaphragm. 

(a)  and  (b)  Under  these  conditions   the   chest    injury  will 
demand  to  be  first  dealt  with. 

(c)  In  an  abdomino-thoracic  wound  the  missile  will  have 

usually  passed  out  of  the  chest. 

(d)  Suture  of  the  diaphragm  is  advocated  for  the  following 

reasons  :  (1)  to  render  respiration  more  easy  ; 
(2)  to  retain  the  blood  in  the  pleura  and  thus  assist 
the  arrest  of  haemorrhage  from  the  lung  ;  (3)  to  pre- 
vent or  reduce  herniation. 

(1)  It  is  still  doubtful  how  far  a  wound  paralyses 

the  diaphragm  or  if  suture  will  restore 
function. 

(2)  It  is  unsettled  if  pressure  by  effused  blood  is  a 

potent  cause  of  arrest  of  haemorrhage. 

(3)  It  is  impossible  to  gauge  the  size  of  the  hole  in 

the  diaphragm ;  the  average  size  can  be  seen 
above.  Large  herniation  does  not  seem  to  be 
the  rule,  and  small  ones  of  the  omentum  are 
not  an  immediate  danger  to  life. 

Although  suture  of  the  diaphragm  is  the  ideal  treatment,  the 
universal  acceptance  of  the  transpleural  route  for  its  accom- 
plishment as  a  primary  measure  would  seem  in  many  cases  to 
involve  a  lengthening  of  the  operation  which  may  be  pre- 
judicial to  the  wounded  man. 

It  would,  therefore,  seem  reasonable  to  advance  the  following 
recommendations  : — 

(1)  That  many  small  thoracic  wounds  may  be  disregarded  ; 

(2)  That  when  there  is  an  open  "  blowing  wound,"  or  respira- 
tory distress,  or  if  the  hypochondrium  is  alone  involved,  the 
lung  condition  should  first  be  attended  to  and  the  transpleural 
route  used  to  treat  the  abdominal  lesion  if  possible. 


124  War  Surgery  of  the  Abdomen 


(3)  In  other  cases  the  abdominal  exploration  should  come 
first  and  the  lung  and  diaphragmatic  lesions  be  attended  to, 
if  advisable,  and  time  permits. 

Mortality  and  Causes  of  Death  :— 


Total  cases 

Operated  and  evacuated 
Operated  and  died 
Unoperated  and  evacuated 
Unoperated  and  died 


101 

31 

39 

7 

24 


In  this  series  neither  suture  of  the  diaphragm  nor  the  trans- 
pleural  route  as  a  primary  measure  was  pushed. 

TABLE    XXX. — To   show   the   Influence   of  Abdomino-thoracic 
Wounds  on  the  Total  Mortality. 


— 

All  Cases. 

Abdomino- 
thoracic. 

Excluding 
Abdomino- 
thoracic. 

Mortality,  including  moribunds 
Mortality,  excluding  moribunds 
Mortality,  operative 

59-5 
49-2 
51-4 

63-0 
50-6 
55-5 

59-2 
48-9 
50-9 

Diaphragmatic  Herniae. 

Considering  the  number  of  times  the  diaphragm  must  have 
been  injured,  the  number  of  cases  that  have  come  to  light  is 
small. 

Putting  aside  those  herniae  (immediate)  that  are  found  at  the 
primary  operation  there  are  others  that  occur  later.  They  may 
be  divided  into  two  classes,  namely  those  that  occur  within 
a  short  time  (intermediate)  and  those  that  come  to  light  after 
a  lapse  of  time  (remote). 

The  intermediate  variety  has  usually  been  found  within  ten 
days  or  so  of  the  wound,  when  an  abdominal  operation  has  been 
called  for  on  account  of  obscure  symptoms  or  at  a  post-mortem 
examination.  The  remote  form  has  been  found  under  similar 
conditions  up  to  twenty-four  months  after  the  wound. 

In   the    intermediate    variety    the    abdominal    viscera    pass 


Diaphragmatic  Herniae  125 

through  when  the  rent  is  made  or  soon  after.  In  the  remote 
form  the  herniation  takes  place  at  a  later  period. 

Morbid  Anatomy. — The  cases  have  all  been  left-sided.  The 
track  of  the  missile  has  often  been  across  both  chests  from  side 
to  side.  In  the  intermediate  form  the  rent  in  the  diaphragm  is 
large,  often  irregular.  In  the  remote  form  it  is  often  much  smaller, 
although  there  is  considerable  herniation  of  viscera.  In  the 
recent  state  the  edges  are  soft  and  irregular,  but  later  on  become 
well  defined  and  somewhat  unyielding.  The  shape,  whatever 
it  was  at  first,  becomes  lenticular  or  ovoid  ;  the  prolapsed 
viscera  tend  to  dilate  and  round  off  the  irregularities.  As  a 
rule  there  is  no  sac,  but  this  has  been  described  in  one  case 
and  may  have  been  due  to  an  incomplete  division  of  the 
diaphragm. 

There  may  be  many  adhesions  or  none.  If  present  they  are 
usually  found  at  the  hiatus,  where  there  may  be  a  few  points  of 
adherence  or  a  complete  marginal  attachment.  The  omentum 
is  mostly  concerned.  Within  the  pleura  there  are  not  usually 
many  adhesions. 

The  amount  of  lung  collapse  is  very  various.  Often  there  is 
a  good  negative  pressure  in  the  thorax  in  the  remote  variety. 

Organs  herniated. — These  are  the  same  as  in  the  immediate 
form,  and  the  omentum  again  is  most  often  found  to  have 
passed  through  the  hole.  Of  the  hollow  viscera  the  stomach 
seems  to  be  frequently  involved  in  the  intermediate  form,  and 
the  colon  and  stomach,  sometimes  accompanied  by  the  small 
intestine,  in  the  remote  form.  In  the  intermediate  variety  the 
stomach  has  been  found  wounded  as  it  lay  within  the  pleura 
and  its  contents  extravasated.  In  the  remote  form  it  may 
have  a  very  distinct  hour-glass  shape,  the  neck  corresponding 
to  the  rent  in  the  diaphragm. 

In  some  cases  the  hernia  is  spontaneously  reduced  to  be  again 
protruded. 

SYMPTOMS. — These  are  often  obscure  and  puzzling.  In  the 
intermediate  form  all  that  usually  attracts  attention  is  rapidity 
of  the  pulse  and  respiration  rate,  the  reason  for  which  cannot 
be  determined. 

In   the   remote   form   the   symptoms   consist   of  abdominal 


126  War  Surgery  of  the  Abdomen 

pain  combined  with  a  disturbance  of  the  gastric  or  intestinal 
function.  Sudden  exacerbation  of  symptoms  followed  by  an 
amelioration  points  to  an  involvement  and  release  of  the  viscera. 

When  the  stomach  is  involved,  disturbances  connected  with 
the  ingestion  of  food  are  the  most  marked,  and  when  the  large 
bowel  is  prolapsed  obstruction  is  the  predominant  feature. 

Gastric  Form. — In  the  gastric  form  there  is  pain  on  taking 
food,  sometimes  trifling,  sometimes  severe.  There  may  be 
difficulty  in  swallowing,  which  difficulty  can  be  overcome  by 
position,  such  as  a  dorsal  or  left-sided  posture.  Vomiting  is 
frequent ;  it  may  be  spontaneous  or  purposely  induced  to  give 
relief.  If  the  hernia  has  been  of  long  standing  there  may  be  great 
emaciation. 

Colic  Form. — Here  there  is  usually  a  history  of  attacks  of 
abdominal  pain  and  constipation,  with  intervals  of  complete 
freedom  from  both.  The  intervals  between  the  attacks  are 
very  various  and  often,  in  the  early  stage,  amount  to  months. 
Later  on  the  intervals  become  shorter.  The  patient  is  usually 
in  good  health  and  well  nourished.  The  pain  is  the  same  as 
that  met  with  in  chronic  obstruction,  but  is  sometimes  ex- 
perienced in  the  left  chest  as  well  as  in  the  abdomen.  Some- 
times the  obstruction  becomes  acute. 

Physical  Signs.- — If  acute  intestinal  obstruction  is  not  present 
the  abdomen  is  nearly  always  normal.  Even  if  the  symptoms 
have  suggested  a  hernia  it  is  possible  that  the  physical  signs 
may  be  quite  unconvincing.  Whether  the  examination  is  helpful 
or  not  depends  lipon  whether  the  hernia  is  large  enough  to 
displace  or  compress  lung,  or  whether  it  contains  air  or  fluid 
and  so  gives  rise  to  abnormal  noises.  As  a  rule  it  is  the  stomach 
that  produces  the  most  pronounced  physical  sounds,  both  from 
its  bulk  and  its  air  and  fluid  contents.  The  colon,  if  the  obstruc- 
tion is  at  the  distal  point  of  the  involved  bowel,  will  cause  very 
much  the  same  signs  as  the  stomach. 

The  actual  physical  signs  noted  are  as  follows  :• — 

(1)  Dulness  and  absence  of  breath  sounds. 

(2)  Feeble  respiratory  murmur  and  increased  resonance. 

(3)  Tinkling,  gurgling,  or  splashingsounds.    These  occur  with 
the  colon,  but  are  more  usually  found  with  the  stomach,  where 


Diaphragmatic  Hernise.  127 

ingestion  of  fluid  may  produce  or  increase  them.  There  has  been 
a  difficulty  in  telling  whether  these  signs  originate  in  the 
abdomen  or  thorax.  When  heard  they  have  not  been  appre- 
ciated at  their  proper  value. 

The  diagnoses  actually  made  have  embraced  the  following  : 
massive  collapse  of  lung,  subdiaphragmatic  abscess  containing 
air,  and  pneumothorax  and  haemothorax. 

X-ray  Examination. — This  has  shown  an  absence  of  the  usual 
lung  shadow  and  an  alteration  in  the  position,  form,  and  motility 
of  the  diaphragmatic  vault.  If  the  stomach  is  the  organ  involved 
a  bismuth  meal  quickly  makes  the  diagnosis,  provided  that  it 
is  herniated  at  the  moment. 

TREATMENT. — This  is  operative.  If  the  diagnosis  has  been 
made,  and  there  are  no  acute  symptoms,  the  transpleural  route 
is  the  best,  and  should  be  used  in  the  first  instance,  though  diffi- 
culties of  reduction  may  necessitate  a  coeliotomy.  When,  how- 
ever, the  diagnosis  is  doubtful  (and  up  till  now  it  has  seldom 
been  made),  the  abdomen  should  be  opened  and  the  actual 
condition  of  things  ascertained. 

A  paramedian  incision  is  best.  There  may  be  an  absence  or 
a  perfectly  obvious"  displacement  of  stomach,  colon,  and  omen- 
turn.  On  the  other  hand,  all  may  appear  normal.  A  manual 
examination  of  the  diaphragmatic  vault  will  quickly  show  the 
presence  and  site  of  the  hernia,  provided  the  contents  are  not 
reduced. 

One  must  be  on  one's  guard  not  to  miss  a  small  colic  hernia. 
Such  a  hernia  produces  no  obvious  displacement  of  the  viscera, 
and  may  be  missed  unless  the  continuity  of  the  transverse  and 
descending  colon  be  carefully  traced.  The  approximation 
at  the  hernial  opening  of  the  proximal  and  distal  ends  of  the 
herniated  loop  may  lead  to  the  belief  that  the  bowel  is  con- 
tinuous within  the  abdomen,  and  that  the  only  abnormality  is  a 
highly  placed  splenic  flexure.  If  there  are  but  few  adhesions 
reduction  may  be  effected  from  the  abdomen,  but  if  there  are 
many  it  will  be  necessary  to  do  this  by  the  transpleural  route. 
A  finger  introduced  through  the  rent  will  indicate  the  best 
position  in  which  to  perform  thoracotomy.  Cowell's  method 
is  to  be  recommended. 


128  War  Surgery  of  the  Abdomen 

Even  after  an  abdominal  reduction  of  the  hernia  contents 
a  thoracotbmy  may  be  necessary  to  close  a  rent  which  is  not 
suturable  from  beneath  the  diaphragm. 

Obscure  abdominal  symptoms  in  a  man  previously  shot 
through  the  lower  chest  should  suggest  the  possibility  of  a 
diaphragmatic  hernia.  If  this  possibility  is  borne  in  mind  a 
diagnosis  will  almost  always  be  made,  although  the  physical 
signs  are  puzzling.  With  the  greater  attention  now  paid  to 
wounds  of  the  diaphragm,  the  number  will  decrease,  but  some  are 
still  likely  to  occur  and  offer  difficulties  in  diagnosis. 


CHAPTER   IX. 

CAUSES  OF  FAILURE. 

COMPLICATING  INJURIES. — One  need  say  very  little  on  this 
subject,  except  that  every  kind  of  bodily  injury  may  be  added 
to  that  of  the  abdomen.  Compound  depressed  fractures  of 
the  skull,  fractured  long  bones,  multiple  wounds,  fractured 
spine,  and  avulsed  limbs,  are  among  such  complicating  injuries. 
In  considering  the  total  mortality,  and  in  appraising  the  worth 
of  abdominal  surgery,  one  must  take  these  injuries  into  account  ; 
but  for  such  extraneous  injuries  the  mortality  would  be  con- 
siderably lower. 

MENTAL  AND  PHYSICAL  STRAIN. — It  is  commonly  said  that  the 
surgeon  in  war  has  an  advantage  over  his  peace  colleague  in 
that  his  subjects  are  healthy  young  adults.  This,  of  course,  is 
true  ;  but  there  is  the  strain  caused  by  days  of  watching  and 
alertness,  and  nights  when  sleep  is  difficult,  interrupted,  or 
impossible  to  obtain.  Then  there  is  the  exertion  of  battle, 
which,  for  the  time  being  at  any  rate,  obliterates  all  sense  of 
fatigue,  so  that  many  men  do  not  know  how  tired  they  are 
until  some  wound  is  received  which  prevents  them  going  farther. 
Next,  there  is  the  journey  to  the  Casualty  Clearing  Station. 
Sometimes  the  men  arrive  practically  asleep,  and  resent  any 
interference  or  examination.  Other  men  arrive  in  whom  a  state 
of  excitement  is  still  present,  and  they  are  willing  and  anxious  to 
chatter  about  their  experiences.  Then,  after  being  fed,  they 
are  dressed,  and  if  they  do  not  fall  asleep  in  the  process  they  do 
so  immediately  afterwards  ;  and  it  is  one  of  the  most  striking 
sights  of  the  medical  side  of  war  to  see  a  large  room  filled  with 
men  lying  on  stretchers,  some  slightly  wounded,  some  severely, 
some  mortally,  but  all  asleep,  and  asking  for  nothing  but  sleep. 
It  is  on  such  patients  that  the  surgeon  has  to  work,  and  it  may 
well  be  imagined  how  much  the  mental  and  physical  strain  may 
increase  the  effect  of  injury. 

W.S.A.  9 


130  War  Surgery  of  the  Abdomen 

HAEMORRHAGE. — Haemorrhage  stands  out  as  a  great  enemy  of 
the  surgeon.    It  comes  from  all  sorts  of  places. 

(1)  Stomach. — Injury  to  the  actual  wall  of  the  stomach  appa- 
rently does  not  cause  much  haemorrhage  ;    but  damage  to  the 
vessels  running  on  the  stomach  wall  before  they  penetrate  it, 
and  to  the  big  vessels  lying  on  the  two  curvatures,  does  give 
rise  to  very  great  haemorrhage. 

(2)  Omentum. — There  may  be  a  fair  amount  of  haemorrhage 
from  this  structure. 

(3)  Small-intestine    Wall. — This   is  a  source  of  considerable 
haemorrhage,   and  in  this  way  is  perhaps  a  contrast  to  the 
stomach  wall.    It  is  not  very  unusual  to  see  coils  of  the  intestine 
filled  with  blood  in  addition  to  that  which  has  escaped  into  the 
peritoneum. 

(4)  Mesentery. — The    mesenteric   vessels    give    rise    to    very, 
considerable  haemorrhage.    A  mesentery  wound  often  includes 
also  a  wound    of  the    big   vessels,    such    as    the    colics,    and 
it  is   most  probable   that   haemorrhage   from   these   vessels   is 
the  most  common  source  of  blood  in  the  abdomen  when  the 
cases  come  to  operation.      The  vessels  in  the  mesentery  are 
unsupported  by  masses  of  muscle,   as  are  the  vessels   in  the 
limbs,    and   for  this    reason   one    of  the  natural  processes   of 
haemostasis  is  wanting,  namely  the  pressure  produced  by  the 
effused  blood. 

(5)  Retroperitoneal  Tissue. — Here  haemorrhage  is  a  source  of 
great  trouble  ;    it  often  raises  the  posterior  abdominal  peri- 
toneum so  as  to  touch  the  anterior  wall  when  the  abdomen  is 
open.    It  may  look  like  a  large  purple  intra-abdominal  tumour. 
This  surface  shows  cracks,  through  which  the  blood  oozes  slowly. 
If  left,  it  may  become  infected  and  the  seat  of  gas  production. 
If,  on  the  other  hand,  any  attempt  is  made  to  find  the  bleeding 
point,  the  difficulty  may  be  very  great,  even  if  the  surgeon  is 
successful.    Whether  this  attempt  is  made  must  depend  on  the 
situation  of  the  haematoma  and  the  likelihood  of  injury  to  the 
big  vessels.     Most  probably  the  best  thing  is  to  leave  it  alone, 
and  to  drain  it  through  the  loin  if  sepsis  intervenes.     There  is 
often  considerable  shock,  out  of  proportion,  I  should  say,  to  the 
amount  of  blood  lost.     The  sources  of  bleeding  are  the  local 


Causes  of  Failure  131 

vessels,  and  sometimes  the  renal  vessels  or  pelvic  veins,  or  even 
the  abdominal  cava. 

(6)  Abdominal  Wall. — In  these  cases  the  deep  epigastric  artery 
is  the  usual  source  of  the  trouble  ;    and  in  one  case  the  whole 
abdomen  was  filled  from  a  wound  of  this  artery. 

(7)  Great  Vessels. — The  big  vessels  injured  are  the  vena  cava 
and  the  iliac  veins,  in  addition  to  the  renal  and  splenic  veins. 
The  abdominal  cava  has  been  closed  by  sutures  by  Captain 
Sampson,  but  the  patient  died.     On  another  occasion  the  rent 
was  successfully  brought  together  by  forceps  by  Captain  Taylor  ; 
the  forceps  were  left  on  for  the  time  being,  and  the  patient 
was  sent  to  the  Base  after  their  removal.     The  iliac  arteries 
have  been  wounded  and   secured.      So  far  no  wound   of   the 
abdominal  aorta  has  been  dealt  with  at  operation,  but  one  was 
found  at  a  post-mortem. 

(8)  Solid  Organs. — The  parenchyma  of  all  solid  organs  bleeds 
freely  at  first ;    but  it  is  probable  that  if  no  large  vessel  is 
injured,  the  haemorrhage  will  cease  spontaneously  in  a  few  hours 
(four  to  eight).    In  one  case,  however,  the  splenic  pulp  was  still 
found  bleeding  after  twenty-four  hours. 

Within  limits  it  is  not  so  much  the  amount  of  blood  lost  that 
causes  collapse  as  the  suddenness  of  the  loss. 

Again,  it  is  difficult  to  detect  any  definite  relation  between 
the  amount  of  blood  loss  and  the  effect  produced.  A  man  can 
without  detriment  lose  by  the  surgical  operation  of  transfusion 
an  amount  of  blood  the  loss  of  which  would  produce  a 
decidedly  bad  effect  on  a  wounded  soldier. 

SEPTIC  ABSORPTION. — This  takes  place  in  four  ways  :  (1)  from 
the  peritoneum,  (2)  from  the  retroperitoneal  tissue,  (3)  from 
the  wound  itself,  and  (4)  from  the  operation  wound. 

(1)  Peritonitis. — There  is  nothing  peculiar  about  the  perito- 
nitis compared  with  that  seen  in  civil  practice. 

Peritonitis  is  the  usual  cause  of  death  after  the  period  of 
shock  and  haemorrhage  is  over  ;  death  may  occur  within  twenty- 
four  hours,  or  be  delayed  for  a  week  or  ten  days.  The  first 
variety  may  be  called  the  fulminating  type,  the  second  the 
dormant.  It  was  the  latter  class  which  was  seen  so  often  at  the 


132  \Var  Surgery  of  the  Abdomen 

beginning  of  the  war.  These  cases  might  or  might  not  show 
signs  of  peritoneum  involvement  when  first  seen.  If  there  were 
such  signs,  with  rest  in  bed  they  would  improve  for  a  day  or  two 
and  give  the  impression  that  things  were  quieting  down.  There 
might  have  been  some  vomiting,  but  this  often  subsided,  and  the 
tongue  kept  clean.  Then  the  abdomen  became  tumid.  But 
the  general  condition  remained  fair,  and  the  pulse,  if  somewhat 
rapid,  was  not  of  bad  quality.  In  some  cases  the  patients 
then  became  obviously  worse  and  died.  In  others  the 
patients  remained  moderately  well,  or  even  appeared  to  have 
improved,  and  were  sent  to  the  Base,  with  the  belief  that 
they  would  recover.  In  some  cases  the  journey  to  the  Base 
seemed  to  light  up  the  septic  process,  and  they  died  soon  after 
arrival.  Others  struggled  on  for  some  time  further.  One  case 
may  be  mentioned  in  this  connection  :  A  man  was  shot  in  the 
abdomen,  kept  at  a  Casualty  Clearing  Station  for  eight  days, 
and  then  evacuated,  apparently  doing  well.  On  arrival  at  the 
Base  he  was  ill,  and  was  found  to  have  a  large  iliac  abscess, 
which  was  incised.  He  died  on  the  following  day.  A  post- 
mortem showed  that  into  the  faecal  abscess  there  opened  two 
moderate-sized  holes  in  the  small  intestine.  It  is  a  remarkable 
fact  that  in  this  case  the  bowels  had  acted  normally  on  several 
occasions. 

The  amount  of  peritonitis  present  when  operation  is  done  at 
an  early  stage  is  very  various,  and  within  certain  limits — to 
judge  by  the  naked-eye  appearances,  which  are  known  to  be 
deceptive — it  is  not  so  dependent  on  the  time  elapsed  since  the 
wound  as  might  be  supposed.  It  has  been  found  present  in  a 
marked  degree  in  the  case  of  a  wound  of  the  upper  ileum  after 
three  hours  and  a  half,  and  has  been  practically  absent  in  the 
case  of  wounds  of  the  jejunum  after  twenty-six  hours.  It 
is  not  altogether  commensurate  with  the  amount  of  faecal 
escape.  As  regards  prognosis,  distension  of  the  intestine  is 
a  better  guide  than  the  amount  of  visible  inflammation.  If 
the  pulse  is  good  when  the  abdomen  is  closed,  the  prognosis  is 
good. 

Peritonitis  is,  of  course,  brought  about  in  some  instances  by 
contamination  from  the  bowel ;  but  one  must  remember  that 


Causes  of  Failure  133 

the  projectile  carries  in  dirt,  even  if  it  does  not  carry  any  cloth- 
ing, and  may  in  this  way  cause  peritonitis  apart  from  any 
bowel  injury.  The  fatal  micro-organism  is  the  streptococcus. 
The  anaerobes  do  not  seem  to  be  able  to  flourish  in  the  abdominal 
cavity.  In  this  way  the  peritoneum  resembles  the  synovial  sacs 
of  joints. 

The  removal  of  the  projectile  is,  of  course,  to  be  desired,  but 
it  is  almost  impossible  to  find  it  in  the  posterior  abdominal 
wall,  and  the  search  for  it  may  result  in  a  great  expenditure 
of  time. 

The  dissemination  of  infection  is  more  a  vital  than  a  physical 
process,  though  of  course  septic  fluid  and  stomach  contents 
do  gravitate  to  the  pelvis.  Bleeding  of  the  mesentery,  when  in 
conjunction  with  a  wound  of  the  bowel,  must  have  a  definite 
influence  in  the  spreading  of  infection.  In  two  cases,  Captain 
Sampson  had  the  blood  in  the  abdomen  examined,  and  this  was 
full  of  streptococci. 

(2)  Rctroperitoneal  Sepsis. — A  series  of  post-mortem  examina- 
tions after  abdominal  injuries  (made  by  Captain  McNee  and 
Captain  J.  S.  Dunn)  has  demonstrated  the  frequency  of  gas 
gangrene  and  retroperitoneal  sepsis  in  cases  supposedly  dead  of 
peritonitis  or  shock.  It  seems  to  be  proved  that  this  cause  of 
death  is  much  more  crmmon  than  one  supposed.  The  condition 
may  occur  in  two  foims  :  (1)  gaseous  or  (2)  non -gaseous.  It 
may  occur  with  or  without  a  bowel  lesion,  but  more  usually 
with  one.  The  colon  is  generally  the  portion  of  the  bowel  impli- 
cated, but  it  may  follow  wounds -of  the  duodenum.  The  infec- 
tion is  often  one  of  extreme  virulence,  so  that  a  man  on  admis- 
sion is  dying,  and  this  even  with  an  open  wound.  In  other 
cases  it  may  follow  a  small  innocent-looking  wound  in  the 
flank.  When,  on  account  of  symptoms,  such  a  wound  is 
explored,  the  retroperitoneal  tissue  may  be  black  and  stinking 
or  full  of  gas.  At  other  times  an  incision  shows  only  some  blood- 
stained areolar  tissue  without  smell.  A  simple  incision  may  be 
all  that  is  necessary,  and  the  symptoms  subside  without  any 
signs  of  violent  infection.  At  other  times  the  discharge  becomes 
foul  and  evil-smelling,  and  the  patient  may  succumb.  Again,  a 
loin  wound  may  go  on  well  for  a  time ;  then  the  patient  may 


134  War  Surgery  of  the  Abdomen 

* 

show  signs  of  absorption,  develop  a  faecal  fistula,  and  recover. 
At  another  time  the  skin  of  the  loin  becomes  bronzed  and 
crepitant,  and  the  man  dies  rapidly  in  spite  of  incision.  Bronzing 
of  the  skin  is  a  curious  manifestation,  and  its  causation  is  not 
altogether  obvious.  In  certain  cases  it  subsides  without  any  ill 
effects  even  if  left  alone  ;  but  it  is  so  often  accompanied  by 
"  gas  infection  "  that  it  is  well  to  incise  it  at  the  earliest  possible 
moment. 

It  is  this  sepsis  which  causes  the  high  mortality  in  cases  where 
a  colon  anus  has  been  found  necessary.  Here  the  bowel  has 
been  widely  wounded  by  the  projectile,  and  the  retroperitoneal 
tissue  and  muscles  have  been  badly  damaged.  It  seems  impos- 
sible to  stop  such  infection  ;  by  the  time  the  case  comes  under 
treatment  it  has  got  too  far  ahead,  even  though  the  patient  at 
the  time  does  not  seem  gravely  ill.  Even  widely  open  drainage 
may  be  impotent. 

A  rather  striking  manifestation  of  the  gaseous  variety  is  seen 
when  a  retroperitoneal  haematoma  becomes  infected.  This  may 
be  palpable  from  the  abdomen  as  a  well-defined  tumour,  but 
resonant  on  percussion.  Exploration  reveals  the  cause^ — a 
gaseous  haematoma. 

(3)  Sepsis  from  the  Projectile    Wound.- — The  wound   caused 
by  the  missile  may  at  any  time  show  signs  of  sepsis  and  gas 
gangrene.    In  fact,  it  behaves  just  like  the  wounds  of  muscle  in 
other  parts  of  the  body,  and  must  be  dealt  with  in  the  same  way. 
It  has  caused  death  in  a  certain  number  of  cases  in  which  the 
intestinal  lesion  has  been  successfully  dealt  with.     It  used  to 
be  said  that  gas  gangrene  was  not  common  in  the  trunk  ; 
experience  has  shown  that  this  immunity  has  been  much  over- 
stated. 

(4)  Sepsis  from  the  Operation   Wound. — This,  too,  becomes 
badly  infected  in  many  cases.     The  cause  may  be  a  faulty 
technique,  but  I  think  it  is  nearly  always  due  to  infection  from 
the  abdomen.    This  is  not  to  be  wondered  at,  when  nearly  all 
abdominal  wounds  are  accompanied  by  blood  effusion,  which  is 
itself  grossly  infective.    Very  often- the  operation  wound  is  the 
seat  of  intense  infection,  although  the  intestinal  lesion  does  well. 
This  is  comparable  with  what  is  seen  in  the  behaviour  of  the 


Causes  of  Failure  135 

operation  wound  and  peritoneum  respectively  in  cases  of  acute 
appendicitis. 

RELATION  BETWEEN  THE  AMOUNT  OF  INJURY  AND  THE 
AMOUNT  OF  COLLAPSE. — Something  may  be  learnt  from  studying 
a  man's  sensations  when  hit.  They  vary  in  a  remarkable 
degree. 

Avulsion  of  portions  of  the  abdominal  wall  may  cause  but 
little  disturbance ;  on  the  other  hand,  it  more  usually  produces 
great  shock,  which  may  be  suddenly  fatal,  either  at  once  or  after 
a  short  interval  of  time.  As  an  example  of  a  slight  effect  the 
following  may  be  quoted  :  A  man  had  his  abdomen  ripped  open 
by  a  bullet  just  as  we  were  compelled  to  evacuate  a  trench.  He 
was  bandaged  up  with  a' field  dressing,  and  insisted  on  walking 
to  a  trench  in  the  rear,  where  he  lay  on  the  fire  step  till  things 
had  quietened  down.  He  was  then  evacuated,  and  made  a 
good  recovery.  The  following  shows  the  opposite  effect  :  A 
party  of  men  were  marching  along  a  road  just  outside  an 
advanced  operating  centre  when  an  aerial  bomb  exploded  in 
their  midst.  Twenty-two  were  brought  in  dead  within  a  few 
minutes.  Twelve  had  abdominal  wounds,  and  of  these  the 
intestines  were  exposed  in  ten  instances. 

Sometimes  a  man  is  unconscious  that  his  intestine  is  pro- 
lapsed. A  soldier  was  hit  just  above  the  pubes  ;  he  experienced 
very  little  inconvenience.  When  the  first  dressing  was  applied 
some  of  the  small  gut  lay  on  the  abdominal  wall.  He  was 
taken  to  hospital,  where  he  arrived  in  good  condition  and  free 
from  pain.  Six  to  seven  feet  of  the  small  gut  lay  outside  the 
abdomen  and  perforated  in  several  places.  He  made  a  good 
recovery. 

Sometimes  a  man  hit  in  the  abdomen  will  believe  that  the 
injury  is  in  the  leg,  a  nerve  having  been  injured  and  giving  rise 
to  reflected  pain. 

Another  man,  who  subsequently  died  of  peritonitis  from  a 
perforated  ileum,  when  seen  six  hours  after  the  injury  was  in 
good  condition,  free  from  pain,  cheerful,  and  smoking  a 
cigarette. 

As  a  rule  a  man  hit  in  the  abdomen  does,  however,  suffer 
pain,  often  intense,  which  dates  from  the  moment  of  infliction. 


136  War  Surgery  of  the  Abdomen 

The  suddenness  of  the  pain  recalls  that  experienced  in  gastric 
perforation ;  it  may  be  accompanied  by  collapse,  transient  or 
persistent. 

Blows  from  large  objects,  such  as  shell  caps,  produce  the 
same  sensation  as  does  any  violent  blow,  such  as  a  kick  from  the 
heels  of  a  horse. 

Small  missiles  may  either  cause  a  sharp  stab  or  the  feeling 
as  if  a  tremendous  blow  had  been  administered.  This  sensation 
is  also  experienced  in  wounds  of  other  parts  of  the  body,  and  it 
is  interesting  to  remember  that  it  is  also  felt  by  those  that 
rupture  muscles  while  playing  games. 

The  actual  comparison  of  the  amount  of  injury  and  the  amount 
of  disturbance  is  a  very  difficult  subject.  There  are  many 
obstacles  in  the  way  of  accurately  gauging  the  bearing  that 
trauma  has  on  collapse.  Regimental  officers  who  see  the  cases 
early  can  form  no  judgment — beyond  gross  lesions — as  to  the 
amount  of  intraperitoneal  damage,  and  by  the  time  the  cases 
reach  hospital  it  is  impossible  to  exclude  other  factors  in  most 
cases. 

Exposure  or  prolapse  of  the  upper  hollow  viscera  causes 
collapse,  and  so  does  avulsion  of  large  portions  of  the  abdominal 
wall. 

Multiple  lesions  of  hollow  viscera  produce  a  high  mortality, 
but  multiple  lesions  mean  a  long  operation  and  are  usually 
accompanied  by  much  bleeding.  It  seems  that  multiple  lesions 
are  not  great  producers  of  collapse  provided  haemorrhage  and 
sepsis  are  absent.  Recovery  has  followed  as  many  as  twenty 
lesions. 

Shattering  wounds  of  spleen  and  kidney  cannot  be  said  to  be 
alarming  injuries  in  themselves.  Extensive  wounds  of  the  liver 
are.  Where  both  kidneys  are  involved  death  follows,  but  this 
cannot  be  attributed  to  collapse. 

Finally,  three  cases  may  be  quoted  to  show  that  abdominal 
injuries  may  at  one  time  completely  incapacitate  a  man  and  at 
another  do  not  at  once  prevent  the  individual  from  continuing 
his  work  :— 

(1)  An  ambulance  driver  was  hit  in  the  abdomen  by  a  shell 
fragment.  He  experienced  severe  pain,  became  collapsed, 


Causes  of  Failure  137 

broke  out  into  a  profuse  sweat,  and  vomited.  He  continued 
collapsed  until  the  operation,  which  revealed  perforative 
lesions  in  the  small  gut  and  a  considerable  amount  of  blood  in 
the  belly.  He  recovered. 

(2)  A  bearer  in  the  Royal  Army  Medical  Corps  wounded  in 
the  intestine,  as  a  subsequent   operation  proved,  was  brought 
to  an  Advanced  Dressing  Station  on  a  stretcher.      As  there 
were  many  wounded  to  be  attended  to,  he  got  up  and  gave  a 
hand. 

(3)  An  airman  was  hit  by  a  shell  fragment  far  behind  the 
German  lines.    He  brought  his  machine  safely  back  and  made  a 
good  landing.     He  reached  a  hospital  in  good  condition.     Two 
holes  in  the  small  gut  were  sewn  up.     He  died  of  acute  sepsis 
of  the  retroperitoneal  tissue  after  forty-eight  hours. 

Clinical  Shock. 

All  the  above-mentioned  factors,  namely  mental  and 
physical  strain,  want  of  sleep,  exposure  to  cold  and  wet,  hunger, 
thirst,  horror,  disturbance,  sepsis,  haemorrhage,  and  possibly  in 
addition  "  pure  shock,"  acting  singly  or  together  in  varying 
proportions,  cause  shock  as  seen  by  the  clinical  surgeon.  They 
are  operative  both  before  and  after  operation,  so  that  no  dis- 
tinction need  be  drawn. 

Clinical  shock  *  is  usually  characterised  by  a  rapid,  weak, 
and  sometimes  imperceptible  pulse,  a  low  blood  pressure,  a 
depressed  body  temperature. 

As  may  be  gathered  from  what  has  been  said  on  a  man's 
sensations  on  being  hit,  shock  commences  in  two  ways.  It  may 
come  on  soon  after  the  receipt  of  the  wound,  the  patient  suddenly 
collapsing,  breaking  out  into  a  cold  sweat,  and  vomiting.  This 
condition  may  pass  off  altogether,  or  pass  off  and  again  become 
established,  or  may  persist  and  deepen.  In  other  cases  it  is 
absent  at  first,  but  gradually  develops,  especially  if  the  patient  is 
not  artificially  warmed. 

A  shocked  man  has  a  lowering  of  his  blood  alkalinity,  and 

*  See  report   on  shock  to  the  Medical  Research  Committee  by  Messrs.  Cannon, 
Fraser,  and  Cowell. 


138  War  Surgery  of  the  Abdomen 

this  fall  in  alkalinity  is  accompanied  by  a  fall  in  blood  pressure. 
What  the  actual  relation  between  the  two  may  be  has  not  yet 
been  established.  This  loss  of  alkalinity  is  increased  by  opera- 
tion and  the  administration  of  an  anesthetic. 

There  are  then  three  conditions  to  be  combated  in  the 
shocked  man :  a  low  body  temperature,  a  low  blood  pressure, 
and  a  low  blood  alkalinity. 

A  Low  Body  Temperature. — The  low  temperature  is  due  to  a 
decreased  production  of  heat.  A  shocked  man  is  almost  like  a 
cold-blooded  animal  and  tends  to  take  the  temperature  of  his 
surroundings.  The  chill  that  a  man  feels  when  he  suddenly 
breaks  out  into  a  cold  sweat  is  due  to  a  constriction  of  surface- 
vessels,  but  this  subjective  sensation  of  cold  is  soon  replaced  by 
an  actual  fall  in  the  body  heat.  The  men  wounded  in  the  bomb 
attack  mentioned  above  were  admitted  into  hospital  so  quickly 
that  they  were  actually  warm  when  put  to  bed,  but  got  cold 
there  before  the  artificial  heat  had  time  to  act. 

Observations  have  shown  that  if  a  man  is  adequately  warmed 
shock  may  be  averted  in  many  instances.  The  first  place  where 
this  can  be  properly  done  is  the  Regimental  Aid-Post.  It  some- 
times takes  an  hour  and  a  half  to  reach  this,  even  if  evacuation 
is  possible.  It  is  important,  therefore,  that  blankets  should  be 
attached  to  all  stretchers.  Morphia  should  be  given  as  soon  after 
injury  as  possible.  All  Regimental  Aid-Posts  should,  if  possible, 
be  well  warmed,  and  arrangements  made  for  heating  the  wounded 
man  by  placing  him  on  a  stretcher,  which  is  converted  into  a 
warm  bed  as  follows.  The  stretcher  is  placed  on  trestles.  The 
blankets  covering  the  stretcher  are  allowed  to  hang  down  over 
the  sides.  The  space  beneath  the  stretcher  is  then  converted 
into  a  hot  air  chamber  by  placing  a  lamp  in  it.  The  man  is  laid 
on  a  folded  blanket,  and  the  patient  when  sent  on  his  journey  is 
covered,  in  addition,  by  the  portions  of  the  two  blankets  that 
have  so  far  hung  down.  He  has  thus  four  thicknesses  of  blanket 
above  and  below  him.  At  the  Regimental  Aid-Post  wet  clothes 
are  removed  provided  the  atmosphere  is  warm  and  there  are 
substitutes.  Hot  fluids  and  a  drachm  of  bicarbonate  of  soda 
are  also  to  be  administered. 

When    the     patient     arrives     at     the    Advanced    Dressing 


Causes  of  Failure  139 

Station  he  is  again  placed  on  a  warmed  stretcher  and  fluids 
administered. 

When  the  hospital  is  reached  the  man  may  be  undressed  and 
put  to  bed  if  not  in  bad  state.  If  in  bad  state  he  should  again 
be  placed  on  a  warmed  stretcher,  and  when  sufficiently  recovered 
undressed  while  still  on  the  stretcher  and  then  placed  in  bed 
and  the  heating  continued  by  means  of  the  electric  or  hot  air 
cradle.  Alkali  should  again  be  given  by  the  mouth,  if  possible, 
if  there  is  no  vomiting. 

Warmth  is  the  most  potent  restorative  we  have. 

A  Low  Blood  Pressure  and  Loss  of  Blood  Alkalinity. — The 
weak  and  rapid  pulse  and  low  blood  pressure  are  due  (in  some 
cases,  at  all  events)  to  a  loss  of  blood  volume. 

This  loss  of  blood  volume  may  be  caused  by  a  direct  haemor- 
rhage, by  stagnation  of  blood  in  certain  vessels,  or  by  the  blood 
fluids  passing  through  the  vessel  walls  into  the  body  tissues. 

As  to  stagnation  of  the  blood  in  certain  areas,  it  can  be  said 
that  there  is  no  clinical  evidence  that  it  is  stored  up  in  the 
abdominal  viscera. 

A  discrepancy  that  has  been  noticed  between  the  cutaneous 
capillary  and  venous  count  may  be  caused  by  an  extra-vascular 
accumulation  of  blood  fluids  in  the  skin  area.  The  pressure 
may  be  raised  by  rest  and  quiet  and  by  fluids  administered  by 
the  mouth  or  rectum.  If  no  result  occurs,  the  question  of 
infusion  or  transfusion  will  arise.  It  is  somewhat  doubtful 
if  either  is  worth  doing  if  the  patient  shows  no  signs  of 
rallying  after  treatment  by  warmth  and  rest  unless  the  patient 
is  obviously  suffering  from  loss  of  blood. 

Isotonic  and  hypertonic  solutions  are  well  nigh  useless  as 
means  of  raising  and  sustaining  the  pressure,  though  they  are 
of  use  in  increasing  the  blood  alkalinity  if  bicarbonate  of  soda 
is  used  instead  of  sodium  chloride. 

The  choice  therefore  seems  to  be  between  blood  transfusion 
and  Bayliss'  6  per  cent.  gu;ii  in  a  2  per  cent,  sodium  bicarbonate 
solution. 

If  a  man  has  bled  much  transfusion  is  by  far  the  best,  but 
Bayliss'  solution  is  a  good  substitute  if  a  donor  is  not  available 
or  if  the  case  is  not  thought  sufficiently  grave. 


140  War  Surgery  of  the  Abdomen 

A  question  arises  as  to  whether  injection  of  fluids  into^the 
veins  should  be  done  before  an  operation  centre  is  reached.  In 
deciding  this  point  it  may  be  doubted  if  it  is  wise  to  raise  the 
blood  pressure  before  the  source  of  the  bleeding  can  be  checked 
by  operation. 


CHAPTER   X. 

STATISTICS,  RESULTS,  AND  THE  FUTURE. 
Mortality  in  the  Preoperative  Days. 

THE  expectant  treatment  of  abdominal  injuries  was  the  method 
of  choice  in  the  armies  of  all  the  combatants  at  the  beginning  of 
the  war.  Gradually,  on  every  side,  the  operative  has  replaced 
the  older  method. 

Although  it  is  very  difficult  to  compare  the  results  of  the  two 
methods,  expectant  and  operative,  some  interest  attaches  to  the 
figures  obtained  in  the  two  periods  respectively.  The  figures 
in  the  preoperative  periods  had  to  be  taken  from  the  admission 
and  discharge  books  of  the  Field  Ambulances  and  Casualty 
Clearing  Stations,  as  no  separate  books  were  kept ;  consequently 
the  figures  could  only  be  computed.  In  the  second  period  special 
books  were  used,  and  the  figures  may  be  taken  as  approximately 
correct. 

Into  nine  Field  Ambulances  over  a  period  of  six  months  there 
were  admitted  1,098  abdominal  wounds,  with  333  deaths — a 
mortality  of  30  per  cent.  In  the  six  Casualty  Clearing  Stations 
during  the  same  period  there  were  admitted  131  cases  of  per- 
forating abdominal  wounds,  with  73  deaths.  From  these  figures 
it  appears  that  the  total  mortality  in  the  Field  Ambulances  and 
Clearing  Stations  was  about  70  per  cent. 

There  were  also  the  deaths  at  the  Base  in  France  to  be  added, 
and  in  the  preoperative  days  to  which  we  now  allude  many  such 
deaths  occurred,  which  would,  as  far  as  can  be  judged,  bring  the 
mortality  up  to  about  80  per  cent.  Makins  gives  the  death-rate 
at  the  Base  among  small-gut  wounds  as  84  per  cent.,  and  among 
colon  wounds  as  46 '4  per  cent,  in  this  period. 

The  period  covered  by  these  figures  was  the  first  six  months 
of  1915. 


142  War  Surgery  of  the  Abdomen 


Method  of  recording  Cases. 

The  figures  quoted  in  this  book  (unless  stated  otherwise)  are 
based  on  all  the  abdominal  wounds  which  reached  an  operating 
hospital  from  a  certain  sector  of  the  line  over  a  period  of 
eighteen  months  (July  1st,  1915,  to  December  31st,  1916).  The 
beginning  of  this  period  coincided  with  the  commencement  of 
the  operative  treatment. 

In  forming  an  estimate  of  the  mortality  of  abdominal  wounds, 
and  what  can  be  done  for  them  by  operative  treatment,  it  is 
necessary  to  include  all  the  cases,  no  matter  at  what  hospital 
they  are  treated.  Results  differ  in  different  hospitals,  more  or 
less  depending  upon  their  distance  from  the  firing  line  ;  they 
will  also  differ  according  to  the  nature  of  the  fighting ;  they  are 
nearly  always  worse  at  the  end  of  a  fight  than  at  the  beginning, 
for  the  cases  admitted  at  the  end  have  often  been  difficult  to 
collect  and  are  therefore  late  in  arriving.  Again,  if  times  are 
quiet,  there  is  plenty  of  time  to  treat  all  cases  adequately  and 
deliberately  ;  at  another  time,  when  active  operations  are  in 
progress,  it  may  be  only  possible  to  pay  attention  to  the  most 
favourable  cases.  It  is  therefore  necessary  not  only  to  reckon 
the  operative  mortality,  but  also  to  bring  into  account  all 
cases  which  die  without  operation.  This  has  been  done  in  the 
present  series.  In  the  case  of  the  moribund,  we  have  their 
numbers,  but  we  do  not  in  every  case  possess  details  of  the 
injury. 

The  statistics  were  collected  in  the  following  way  :  Every 
hospital  which  was  called  upon  to  treat  abdominal  cases  was 
provided  with  a  book,  in  which  certain  headings  were  written 
down,  and  these  were  filled  in  at  the  time  of  operation  by  the 
medical  officers.  These  books  were  provided  by  the  Medical 
Research  Committee. 

Comparative  Mortality  at  Different  Hospitals. 

Table  XXXI.  shows  the  variations  in  results  which  may  be 
obtained  in  different  hospitals. 


vStatistics,   Results,  and  the  Future         143 


TABLE  XXXI. — Variations  in  the  Results  obtained  in  Different 

Hospitals. 


Mortality. 

Unit. 

Total. 

Operative. 

(1)  A  Casualty  Clearing  Station 

54 

45 

(2)              „              „              „                 .... 

72-7 

— 

(3)  An  abdominal  hospital 

36-4 

— 

(•!•)              „              „              „                 .... 

82-6 

48-8 

(5)  A  Casualty  Clearing  Station 

50 

44-4 

(6)  An  abdominal  hospital 

56-4 

52-6 

Note. — (1),  (2),  (3),  (4)  During  same  battle.    (5)  Same  as  (1)  but  in  a 
quiet  time.    (6)  Same  as  (3)  in  a  quiet  time  over  a  six-months  period. 

TABLE  XXXI.A. — Results  obtained  in  1917  (Fighting  and  Quiet 
Times)  in  Sectors  that  were  adjacent. 


Unit. 

Total. 

Operative. 

A  Casualty  Clearing  Station  .  . 

>J                                   55                                S>                                                 .... 

An  advanced  operating  centre 

44-3 
68-3 
65 

39-6 
62-4 
56-9 

Mortality. 


TABLE   XXXI. B. — Some  other  Results  from  other   Portions  of 
the  Line  in  1916  during  Fighting. 


Total. 

Operative. 

(1)  An  advanced  operating  centre 

G4-3 

58-5 

(2)  A  Casualty  Clearing  Station 

65-8 

51-9 

(3)  An  advanced  operating  centre 

— 

51 

(4)  A  Casualty  Clearing  Station 

76-5 

80-9 

Mortality. 


(4)  Was  situated  behind  (3)  and  only  took  in  cases  when  (3)  was 
full,  usually  towards  the  end  of  a  fight. 

Results  of  Operative  Treatment. 

The   period   during  which   detailed   statistics   are   available 
covers  the  time  between  July  1st,  1915,  and  December  31st,  1916. 


144 


War  Surgery  of  the  Abdomen 


The  results  of  the  operative  treatment  have  also  been  com- 
piled up  to  September  30th,  1917. 

TABLE  XXXI. c. — To  show  Results  in  Successive  Periods. 


— 

July  1st, 
1915,  to 
Dec.  31st, 
1915. 

July  1st, 
1915,  to 
Dec.  31st, 
1916. 

July  1st, 
1915,  to 
Sept.  30th, 
1917. 

Jan.  1st, 
1917,  to 
Sept.  30th, 
1917. 

Total  cases     .  . 

511 

1,288 

2,127 

839 

Moribund  cases 

145 

250 

420 

170 

Total     mortality, 

excluding 

moribund    .  . 

.  .          .  . 

45-8 

50-06 

50-02 

49 

Total     mortality, 

including 

moribund    .  . 

,    , 

01-25 

60-2 

59-9 

59-5 

Considered     with 

view     to 

operation     .  . 

.  .          .  . 

366 

1,038 

1,707 

669 

Operation  not  thought  neces- 

sary 

.  . 

56 

73 

102 

29 

Total  operations 

.  . 

310 

965 

1,605 

640 

Total  operative  mortality    .  . 

53-9 

53-9 

52-9 

51-3 

Hollow  viscera 

»>            •  • 

64-5 

64-7 

— 

— 

Stomach* 

>» 

43-75 

52-7 

— 

— 

Small  gut* 

•  • 

63-8 

65-9 

.  — 

— 

Colon* 

?»            •  • 

60 

58-7 

— 

— 

"  Uncomplicated  by  any  other  lesion  of  the  alimentary  canal. 

The  above  table  shows  the  results  obtained  over  extending 
periods  of  time,  starting  from  the  commencement  of  the  opera- 
tive treatment.  The  first  and  latest  periods  can  be  compared  in 
first  and  last  columns. 

The  uniformity  of  the  figures  is  rather  remarkable. 

TABLE  XXXII. — Short  Table  of  Operations,  showing  also  the 
Number  of  Operated  and  Non-operated  Cases,  July  1st, 
1915,  to  December  3lst,  1916. 


Operations. 

To  Base. 

Died. 

(1)  Suture  of  stomach 
(2)           ,,               ,,       and  other  operations  on 
the  intestinal  tube 
(3)  Resection  of  small  gut 
(4)          ,,             „         .,       and  other  operations 
on  the  intestinal  tube  not  included  in  (2)  .  . 

26 

6 
26 

5 

29 

21 

89 

34 

Statistics,   Results,  and  the  Future 
TABLE  XXXII. — Continued. 


'45 


Operations. 


To  Base. 


Died. 


(5)  Suture  of  small  gut     . . 

(G)         „  „        „  and  other  operations  on 

the  intestinal  tube  not  included  in  (2) 

(7)  Formation  of  small-gut  anus 

(8)  For  small-gut  fistula 

(9)  Suture  of  colon 

(10)  Formation  of  colon  anus 

(11)  For  wounded  rectum  (proximal  colostomy 

not  included) 

(12)  Proximal  colostomy 

(13)  Coeliotomy,  no  hollow  viscus  perforated    . . 

(14)  ,,  liver  wounded 

(15)  Kidney,  exploration  of 

(10)       „       excision  of       . .          . . 
(17;  For  wounded  bladder 

(18)  Spleen,  exploration  of 

(19)  „       excision  of     . . 

(20)  Miscellaneous  operations 

(21)  No  operation  advised 

(22)  ,,  moribund 


Totals 


Grand  total 


59 
17 

2 

50 
13 

3 

4 

89 
76 
25 

G 

11 
12 

4 

10 
69 


71 


513 


775 


1,288 


TABLE  XXXIII. — Details  of  Operations,  etc.,  shown  in 
Table  XXXII. 


Operations. 

To  Base. 

Died. 

Total. 

Suture  of  stomach 

26 

29 

55 

,,             ,,          and  small  gut 

4             6 

10 

Suture  of  stomach  and  small  gut  ;    gastro- 

jejunostomy 

— 

2 

2 

Suture  of  stomach  and  great  gut 

2 

3 

5 

,,             ,,         „  colon  ;  gastro-jejunostomy 

— 

1 

1 

,,             ,,         small  gut,  and  colon 

— 

3 

3 

Suture  of  stomach  ;    resection  of  small  gut  ; 

gastro-jejunostomy 

—  • 

2 

2 

Suture  of  stomach  and  colon  ;    resection  of 

small  gut 

— 

1 

1 

W.S.A.                                                                                                                                                                     10 

146  War  Surgery  of  the  Abdomen 

TABLE  XXXIII.— Continued. 


Operations. 

To  Base 

Died. 

Total. 

Suture  of  stomach  ;    resection  of  small  gut  ; 

gastro-jejunostomy  ;   colon  anus 

— 

1 

1 

Suture  of  stomach  ;   colon  anus 

— 

2 

2 

Resection  of  small  gut  ;  circular  enterorrhaphy 

18 

69 

87 

lateral  anastomosis    .  . 

8 

18 

26 

gastro-jcjunostomy  .  . 

— 

2 

2 

suture  of  colon 

4 

17 

21 

colon  anus 

1 

14 

15 

suture  of  rectum 

— 

3 

3 

Suture  of  small  gut 

59 

71 

130 

,,             ,,          and  colon.  . 

16 

26 

12 

Suture  of  small  gut  ;  resection  of  colon 

— 

1 

1 

,,             ,,             colon  anus 

1 

5 

6 

Suture  of  small  gut  and  rectum 

— 

1 

1 

Small-gut  anus   .  . 

— 

7 

7 

,,       fistula 

2 

1 

3 

Suture  of  colon  — 

Caecum 

8 

5 

13 

Ascending  colon 

13 

12 

25 

Hepatic  flexure 

7 

9 

16 

Transverse  colon 

5 

8 

13 

Splenic  flexure 

4 

6 

10 

Descending  colon 

6 

3 

9 

Pelvic  colon 

7 

9 

16 

Colon  anus 

13 

36 

49 

On  rectum,   intraperitoneal   wounds 

1 

2 

3 

,,            extraperitoneal       ,, 

2 

3 

5 

Proximal  colostomy 

4 

10 

1  I 

Cosliotomy,  no  hollow  viscus  perforated 

77 

30 

107 

„            non-penetrating  wounds 

12 

3 

15 

On  liver 

76 

38 

114 

On  kidney  :   exploration 

25 

7 

32 

„           nephrectomy 

6 

7 

13 

For  wounds  of  bladder  — 

Extraperitoneal  — 

Suprapubic 

6 

9 

15 

Drainage  of  wound 

3 

1 

4 

Suture 



1 

1 

Intrape  ritoneal  — 

Suprapubic 

— 

1 

1 

Suture 

2 

2 

1 

For  wounds  of  spleen  :   exploration    .  . 

12 

\. 

16 

»>.            ,,               N|)lcnectomy 

1 

12 

16 

For  faecal  abscess 

1 

6 

7 

For  loss  of  belly  wall 



1 

1 

For  prolapse  of  viscera.  . 

6 

3 

9 

Statistics,   Results,  and  the   Future        147 
TABLE  XXXIII.—  Continued. 


Operations. 

To  Base. 

Died. 

Total. 

Tube  to  pelvis 



4 

4 

For  contusion  of  belly 

— 

2 

2 

Loin  wound  enlarged 

3 

2 

5 

No  operation  (no  indication) 

69 

4 

73 

„             moribund 

~ 

250 

250 

Note. — This  table  shows  the  number  of  individuals  operated  upon. 
In  the  case  of  the  intestinal  tract  it  shows  the  number  of  times  the 
different  parts  were  hit.  The  bladder  and  solid  organs  only  appear 
in  the  table  when  they  were  the  principal  viscera  damaged. 

The  Future. 

There  can  be  no  doubt  that  the  success  obtained  has  been 
due  to  several  factors.  These  are  mainly— 

(1)  The  magnificent  way  in  which  the  wounded  are  collected 
by  the  bearers,  both  regimental  and  those  belonging  to  the 
Field  Ambulances.     Honestly,  one  cannot  sufficiently  express 
one's  admiration  for  their  courage,  steadfastness,  and  endurance. 

(2)  The  motor  ambulances  of  the  Field  Ambulances  and  of 
the  motor  convoys.     What  praise  is  not  due  to  the  drivers 
who  in  darkness  and  shell-fire  tenderly  pick  their  way  among  the 
holes  in  the  road  so  as  to  avoid  a  needless  jolt  to  their  wounded 
charges  ? 

(3)  The  fixity  of  the  fighting  line,  which  has  allowed  the 
Clearing  Station  to  develop  to  its  present  condition. 

(4)  The  wisdom  of  those  that  administer  the  Royal  Army 
Medical  Corps  in  that  they  have  abandoned  the  old  tradition 
that  operations  cannot  be  performed  near  a  fighting  area. 

Can  the  past  results  be  maintained  if  the  fighting  becomes 
open  and  the  armies  get  on  the  move  ?  Motor  ambulances  can 
diminish  distance,  but  they  cannot  entirely  obliterate  it. 

It  all  depends  on  whether  the  Casualty  Clearing  Stations  can 
be  moved  sufficiently  quickly. 


INDEX 


ABDOMEN, 
flushing  the,  63 
rigidity  in,  54 
Abdominal  drainage,  63 
hospitals,  46,  49,  143 
surgery, 1,  9,  13 

causes  of  failure,  129 

comparative  mortality  at  different 

hospitals,  142 
complicating  injuries,  129 
future  outlook,  147 
haemorrhage  in,  130 
mental  and  physical  strain,  129 
method  of  recording  cases,  142 
mortality  in  pre-operative  days,  141 
mortality  statistics,  6 
results  in  1916—1917,  143 
results  in  successive  periods,  144 
results  of  operative  treatment,  143 
statistics,  results  and  the  future,  141 
variations    in    results    in    different 

hospitals,  143 
viscera  wounded  in  abdomino-thoracic 

injuries,  121 

wall,  haemorrhage  from,  131 
wounds,  commencement  of  operative 

treatment,  9 
nature  of  the  projectiles  causing,  14, 

16 

question  of  operation,  59 
relative  frequency  of,  14 
relative   number   of   different    pro- 
jectiles   and    the    proportion    re- 
tained, 18 

selection  of  cases  for  rapid  evacua- 
tion, 13 

surgical  opinion  when  war  started,  4 
Abdomino-thoracic  wounds,  22 
abdominal  organs  wounded,  121 
diaphragmatic  lesions,  120 
frequency  of,  119 
influence  of  wounds  of  hollow  viscera 

on  mortality,  122 
influence  on  mortality,  124 
injuries  to  individual  organs,  table,  122 
mortality  and  causes  of  death,  124 
nature  of  projectiles,  120 
organs  herniated,  120 
projectiles  causing,  120 
side  wounds,  119 
treatment  of,  122 
viscera,  wounded,  table,  121 
Advanced  dressing  station,  46 

position  of,  13 

Advanced  operating  centre,  13 
Alimentary  canal, 

state  of,  in  respect  of  nervo-muscular 

mechanism,  42 
in  respect  to  its  contents,  41 
wounds  of,  in  respect  to  contents,  41 
Alimentary  organs,  solid,  wounds  of,  100 
Allies,  experiences  of  the,  9 


Antero-posterior  wounds 

below  intertubercular  plane,  28 
between   transpyloric  and  intertuber- 
cular planes,  27 

Antiseptics,  2 

Anus,  artificial,  92 

Armour,  defensive,  19 

Asepsis,  2 

BACK,  wounds  on,  to  be  first  treated,  60 
Base,  information  from,  to  the  Front,  38 
Bayonet  wounds,  18 
Belgian  Army,  abdominal  hospitals  of, 

49 

Bile,  escape  of,  103 
Bladder,  wounds  of, 

associated  injuries,  116 
complicating  small  intestine  wounds, 

high  mortality  of,  82 
frequency  of,  116 
mortality  and  causes  of  death,  118 
nature  of  injuries,  117 
symptoms  of,  117 
table  of,  116 
treatment  of,  117 
Blood, 

alkalinity  of,  137 
loss  in  shock,  139 
Blood  pressure,  low,  in  shock,  139 
Blood-vessels,  injuries  of,  131 
Bomb  wounds,  52 
Bombs,  17,  19 

Bone  fragments,  indriven, damage  by,  32 
Bullets, 

"explosive  effect"  of,  37,  39 
injuries  of  small  intestine  by,  72,  74 
nature  of  wounds  caused  by,  15,  19 
varieties  of,  14,  16 
velocity  and  stability  of,  15,  37 
wounds,  types  of,  35 
Buttock  wounds,  22 

CAECUM,  wounds  of,  83,  84,  87 

treatment  of,  91 
Cases,  method  of  recording,  142 
Casualty  clearing  stations,  7,  13,  46,  143 
Chest,  abdomino-thoracic  wounds,  22. 

See  also  Abdomino-thoracic  wounds. 
Clinical  shock,  137 
Coeliotomy,  29 
Collapse,   amount   of,   relation   between 

injury  and,  134,  135 
Collection  and  evacuation  of  wounded,  11 
Colon, 

ascending,   wounds   of,   treatment   of, 

88,  91 
character  of  lesions  in  different  parts 

of,  87 
descending,  wounds  of,  treatment  of, 

88,  91 

flexures  of,  wounds  of,  89,  91 
healing  of,  31 


I  ndex 


149 


Colon — continued. 

hollow  viscera  injured  in  conjunction 
with,  83 

injuries  of,  table,  92 

mortality  of  different  parts  of,  93 

pelvic,  wounds  of,  89,  91 

"  septicaemia,"  89 

transverse,  wounds  of,  87,  91 

wounds  of,  mortality  of,  92,  93 
Colostomy 

in  rectal  injuries,  95 

proximal,  92 

DIAGNOSIS, 

appearance  in,  52 

considered  generally,  51 

experience  in,  52 

inspection  in,  51 

intrapcritoneal  damage,  51 

symptoms  in,  52 
Diaphragmatic  herniae,  124 

colic  form,   126 

gastric  form,  126 

morbid  anatomy,  125 

organs  herniated,  125 

physical  signs,  126 

symptoms  of,  125 

treatment  of,  127 

X-ray  examination,  127 
Diaphragmatic  lesions,  120 
Drainage,  abdominal,  63 
Drink  before  operations,  57 

EPIGASTRIC  wounds,  26 

Evacuation  of  wounded,  11 
in  earlier  period  of  the  war,  7 
rapid,  selection  of  cases  for,  13 

Expectant  treatment,  1,  4,  6,  9 

"  Explosive  effect "  of  bullets,  37,  39 

FIELD  ambulance,  47 

Fluids,  withholding,  before  operation,  57 

Flushing  the  abdomen,  63 

Fractures,  compound,  2 

France,  abdominal  surgery  in,  9 

French  Army,  abdominal  hospitals  of,  49 

bullets,  15 

Frequency  of  different   projectiles   met 
with  and  of  those  retained,  19 

of  stoms-ch  wounds,  65 

of  wounds  of  different  viscera,  24,  41 

relative,  of  abdominal  wounds,  14 
Front,  information  to,  from  Base,  3,  8 

('•  \\CUEXE,  gas,  133 

Genito -urinary  organs,  wounds  of,  109 

German  bullets,  15 

Grenades,    17,    19 

II  KMATURIA  in  wounds  of  kidney,  111 
Hemorrhage 

chief  cause  of  early  death,  10 

in  abdominal  surgery,  130 

in  diagnosis,  54 

in  wounds  of  liver,  102,  103 

in  wounds  of  stomach,  69 
Helmets,  steel,  19 
Herniae,  diaphragmatic,   124 
High-explosive  shells,  16,  17 


Hospital, 

preparation  of  patient  for  operation,  58 
variation  in  results,  143 
Hypochondriac  area,  wounds  of,  21,  22 
wounds,  an tero -posterior,  oblique  and 

vertical,  26 

lateral  and  posterior,  27 
Hypogastric  wounds,  21 

INCIDENCE  of  abdominal  wounds,  20 

regional,  of  wounds,  21,  22 
Incision, 

closure  of,  62 
site  of,  60 
transverse,  61 
vertical,  61 

Incisions  in  intestinal  operations,  90 
Infarction,  84 
Injuries,    relative    frequency   of   organs 

involved,  24,  41 
Injury  and  amount  of  collapse,  relation 

between,  134,  135,  136 
Inspection  in  diagnosis,  51 
Intertubercular  plane,  wounds  below,  28 
Intestine  and  intestines, 

condition  of,  post-operative,  63 
large,     associated    wounds    of    other 

viscera,  83 
wounds    of,    character   in    different 

parts,  87 

escape  of  contents,  87 
frequency  of,  82 
infarction,  84 

method  of  dealing  with  lesions,  90 
mortality  and  causes  of  death,  92 
in  respect  to  its  contents,  42 
nature  of  injuries,  83 
protrusion  of,  98 
proximal  colostomy,  92 
symptoms,  89 
treatment  of,  90 

ulceration  of  mucous  membrane,  84 
resection  of,  length  involved,  76 
short-circuiting  of,  80 
small,  divided  in  seven  places  by  rifle 

bullet,  36 

haemorrhage  from  wall,  130 
healing  of,  31 
rupture  of,  34 
state  of,  in  respect  to  nervo-muscular 

mechanism,  43 

state  of,  in  respect  to  its  contents,  41 
suture  of,  circular  and  lateral,  table 

of  results,  80 
wounds  of,  41,  76 

associated  wounds  of  other  organs, 

71 

average  number  in  fatal  and  suc- 
cessful cases,  82 
by  bombs,  75 
by  bullets,  72,  74 
by  shell  fragments,  74 
circular  v.  lateral  suture,  80 
different  parts  compared,  82 
frequency  of,  71 

intimate  nature  of  the  lesion,  75 
length  of  bowel  involved,  76 


Index 


Intestine  and  intestines — continued. 
1  small,  wounds  of — continued. 
lesions  of  mesentery,  75 
microscopical  appearance,  75,  77 
mortality  and  causes  of  death,  81 
mortality,    high,     of     associated 

bladder  wounds,  82 
mortality   of  operative  and  pre- 

operative  periods,  93 
nature  of,  71 
number  of  injuries,  76 
results  of  suture  and  resection,  79 
sepsis  in,  81 

suture  or  resection,  79,  80 
treatment  of  a  prolapsed  knuckle, 

81 

traumatic  paralysis  of,  44 
wounds  of,  4,  66 
Intraperitoneal 

damage,  diagnosis  of,  51 
wounds,  117 

JAUNDICE  in  wounds  of  liver,  103 
Jejunum, 

gunshot  perforation,  73,  78 

lacerated     wounds     caused     by     rifle 
grenade,  75 

KIDNEY, 

bullet  wound  of,  110,  112 
comminution  of  upper  half  of,  113 
indirect  effects  of  gunshot,  33 
minimal  injury  to,  114 
oblique  perforation  of,  111 
wounds  of,  associated  injuries,  109 

complicated  with  wounds  of  other 
organs,  109 

excretion  of  urine,  111 

extravasation  of  urine,  111 

frequency  of,  109 

hsematuria,    111 

mortality  and  causes  of  death,  115 

nature  of  lesions,  109 

operations  for,  table,  115 

secondary  complications,  112 

symptoms,   1 10    • 

treatment  of,  114 

LIVER, 

penetrating  wound  of,  102 

rupture  and  laceration  of,  by  bullet,  38 

vertical  wound  of,  101 

wounds  of,  associated  wounds  of  other 

organs,   100 
biliary  function,  103 
frequency  of,  100 
haemorrhage  in,  102,  103 
mortality  and  causes  of  death,  104 
nature  of  injuries,  100 
organs  injured  in  conjunction  with, 

100 

symptoms  of,  102 

treatment  of,  104 

Lungs,  wounds  of,  123,  125 

MECHANISM  of  wound  production  after 

penetration,   34 
Mental  strain  and  abdominal  injuries,  129 


Mesentery, 

haemorrhage  from,  130 
lesions  of,  75 
Mid-line  wounds,  21 

Missile,    direction   of,    and   position    of 

wound,  influence  on  prognosis,  21 

Moribund  cases,  table  showing  injuries 

in,  24 

Morphia,  administration  of,  before  opera- 
tion, 57 
Mortality, 

comparative,  at  different  hospitals,  142 
effect  of  time  of  operation,  45 
in  pre-operative  days,  141 
increased  by  complications  of  wounds 

of  small  intestine,  table,  81 
influence  of  abdomino-thoracic  wounds 

on,  table,  124 

.influence  of  wounds  of  hollow  viscera 
in  abdomino-thoracic  injuries,  122 
of  colon  wounds,  92 
of  different  parts  of  spleen,  table,  93 
of  liver  wounds,  104 
of    resections    and    sutures    of    small 

intestine,  causes  of,  81 
of  small  intestine  and  colon  wounds, 
operative       and       pre-operative 
periods,  93 

of  stomach  wounds,  70 
of  various  projectiles,  20 
relative,  of  different  projectiles,  20 
statistics  in  abdominal  surgery,  6 

NEPHRECTOMY,  table  of  operations,  115 
Nervo-muscular  mechanism  in  alimentary 
canal,  42 

(ESOPHAGUS,  wounds  of,  65 
Omentum, 

behaviour  of,  in  abdominal  wounds,  98 

haemorrhage  from,  130 

protrusion  of,  96 
Operating  vans,  mobile,  47 
Operation, 

care  of  patient  before,  57 

cases  not  suitable  for,  59 

cases  too  serious  for,  21 

progress  of  patients  after,  64 

question  of,  decisions,  59 

recoveries  without,  25 

wound,  sepsis  from,  134 
Operations,  table  of,  144,  145 
Operative  treatment,  commencement  of, 

9 

Organs,  abdominal,  frequency  of  wounds 
of,  24,  41 

wounded     in    abdomino-thoracic     in- 
juries, table,  122 

PAIN  in  diagnosis,  56 
Pancreas,  wounds  of, 

associated  injuries,  105 

frequency  of,  105 

prognosis,  105 
Patients, 

care  of,  before  operation,  57 
in  hospital  before  operation,  58 

progress  after  operation,  64 


Index 


Peritoneal  cavity,  treatment  of,  63 

Peritoneum,  care  of,  62 

Peritonitis,  131 

Physical  strain  and  abdominal  injuries, 

129 

Posterior  and  lateral  wounds  of  hypo- 
chondriac regions,  27 
Post-operative  treatment,  63 
Prognosis,  effect  of  pulse,  53 
influence  of   position   of  wound   and 

direction  of  missile,  21 
Projectile  wound,  sepsis  from,  134 
Projectiles    causing    abdomino-thoracic 

wounds,  120 
different,  relative  frequency  met  with, 

and  of  those  retained,  19 
nature  of, 
bayonet,  18 
bombs,  17 
bullets,  14 
grenades,  17 
high-explosive  shells,  17 
shell  fragments,  15 
shrapnel,  17 
trench  mortars,  18, 
which  cause  the  wounds,  14,  16 
proportion  retained  in  wounds,  19 
relative  mortality  of  different,  20 
Protrusion  of  omentum  and  viscera,  96 

of  viscera,  120,  125 
Pulse, 

effect  of  prognosis  on,  53 
in  diagnosis,  53 

RECTUM, 

injuries  of,  table,  94 
large  perforation  of,  97 
wounds  of,  associated  injuries,  94 
character  of  lesions,  94 
frequency  of,  94 
treatment  of,  95 
Regimental  aid -post,  46 

position  of,  11 

Regional  incidence  of  wounds,  21,  22 
Resection, 

in  treatment  of  wounds  of  small  intes- 
tine, 79 
of  small  intestine,  causes  of  death,  81 

table  of  results,  79 
Results  of  operative  treatment,  143 
Retro  peritoneal  sepsis,  133 

tissue,  haemorrhage  from,  130 
Rigidity  in  diagnosis,  54 
Rupture    and    laceration    of    liver    by 

bullet,  38 
of  hollow  organs  by  indirect  violence, 

33 
of  solid  organs  by  indirect  violence  of 

passing  projectile,  32 
of  viscera  by  contusion   of  stomach, 

32 
outside  actual  course  of  projectile,  32 

SKMI-  VERTICAL     wounds     below     inter- 
tubercular  plane,  28 
Sepsis  from  operation  wound,  134 
irom  projectile  wound,  134 


Sep  ?is — contin  ued. 

in  wounds  of  small  intestine,  81 
retro  peritoneal,  133 
Septic  absorption,  131 
Shell-caps,  17 
Shell  fragments,  15,  16 
Shells,  high-explosive,  16,  17 

position  of  burst  in  relation  to  wound, 

17 
Shock, 

body  temperature  in,  138 
characteristics  of,  138 
clinical,  137 

loss  of  blood  alkalinity  in,  139 
low  blood  pressure  in,  139 
Shrapnel,  17 
Side-to-side  wounds,  21,  22 

below  intertubercular  plane,  28 
Solid  organs,  haemorrhage  from,  131 
South  African  War,  influence  on  surgical 

opinion,  4,  6 
Spinal    abdomen,     significance    of,     in 

diagnosis,  56 
Spleen, 

bullet  wound  of,  108 
complicating  injuries  of,  106 
wounds  of,  associated  injuries,  106 
frequency  of,  106 
mortality  and  causes  of  death,  108 
nature  of  injuries,  106 
symptoms  of,  106 
treatment  of,  107 
Statistics,  comparative,  141 
Stomach, 

bullet  wound  of  anterior  wall,  68 

haemorrhage  from,  130 

healing  of,  30 

protrusion  of,  98 

wounds    of,     associated     wounds    of 

hollow  viscera,  66 

associated  wounds  of  solid  viscera,  67 
frequency  of,  65 
haemorrhage  and  complications,  69, 

70 

in  respect  to  nervo-muscular  mecha- 
nism, 42 

in  respect  to  its  contents,  41 
mortality  and  causes  of  death,  70 
nature  of,  67,  69 
prognosis,  70 

secondary  complications,  70 
situation  of  injury,  66 
symptoms,  69 
treatment  of,  69 
Strain,  mental  and  physical,  129 
Stretcher-bearers,  11 
Stretchers,  kinds  of,  12 
Surgery, 

abdominal,  causes  of  failure,  129 
exchange  of  knowledge,  3 
experiences  of  the  Allies,  9 
opinion  when  the  war  started,  4 
utility  of  former  experience,  2 
war  and  civil  conditions,  1 
Suture, 

circular  and  lateral,  of  wounds  of  small 
intestine,  table  of  results,  80 


152 


Index 


Suturo — continued. 

in  treatment  of  wounds  of  small  intes- 
tine, 7!) 
of  small  intestine,  causes  of  death,  81 

table  of  results,  79 
Symptoms  in  diagnosis,  52 

TEMPERATURE,  body,  in  shock,  138 

Tenderness  in  diagnosis,  56 

Thorax.     See  Chest ;  see  also  Abdomino- 

thoracic  wounds.    • 

Time  and  mortality,  effect  of,  table,  45 
Transit    to    hospital,    care    of    patient 

during,  57 
Transpyloric  and  intertubercular  planes, 

wounds  between,  27 
Transpyloric  plane,  wounds  above,  25 
Treatment, 

considered  generallj',  51 

expectant,  1,  4,  6,  9 

method   of,   in   earlier  period   of  the 
war,  7 

of  abdomino-thoracic  wounds,  122 

of  bladder  wounds,  117 

of  diaphragmatic  hernke,  127 

of  kidney  wounds,  114 

of  large  intestine  wounds,  90 

of  liver  wounds,  104 

of  peritoneal  cavity,  63 

of  rectum  wounds,  95 

of  small  intestine  wounds,  76 

of  spleen  wounds,  107 

of  stomach  wounds,  69 

operative,  commencement  of,  9 
results  of,  143 

post-operative,  63 
Trench  mortars,  18 
Trenches,  carriage  of  wounded  along,  12 

ULCERATION    of   mucous   membrane   of 

large  intestine,  84 — 86 
Units,  sympathetic  working  between,  4,  8 
Ureter,  wounds  of,  116 
Urine, 

excretion  of,  in  wounds  of  kidney,  111 
extravasation  of,  in  wounds  of  kidnev, 
111 

VEINS,  injection  of  fluids  into,  139 
Velocity  and  stability  of  modern  bullets, 

15,37 

of  shell  fragments,  17 
Viscera,  • 

abdominal,    wounded    in    abdomino- 
thoracic  injuries,  table,  121 
comparative  frequency  of  wounds  of, 

41 

escape  of,  in  penetrating  wounds,  29 
hollow,  injured  with  different  parts  of 

colon,  ,s:{ 
possibility  of  spontaneous  recovery 

after  perforation  of,  30 
rupture  of,  33 

wounds  of,   influence  on   mortality 
in    abdomino-thoracic    injuries, 

122 
treatment,  65 


Viscera — continued. 

injury  of,  by  bone  fragments,  32 
protrusion  of,  90,  120,  125 
rupture  of,  by  contusion  of  stomach,  .'52 
outside  actual  course  of  projectile,  32 
wounded     in     abdomino-thoracic     in- 
juries, 121 
wounds  of,  associated  with  wounds  of 

stomach,  60,  67 
Vomiting  in  diagnosis,  f>4 

WAR, 

method  of  treatment  in  earlier  period 

of,  7 

surgery  as  distinct  from  civil  surgery,  1 
surgical  opinion  at  commencement  of,  4 
Water,  withholding,  before  operation,  57 
Wounded, 

cases  too  serious  for  operation,  21 
collection  and  evacuation  of,  1 1 
evacuation  of,  in  earlier  period  of  the 

war,  7 

mental  attitude  of,  8 
selection  of  cases  for  rapid  evacuation, 

13 
Wounds,    abdominal,    cases    recovering 

without  operation,  25 
cases  too  serious  for  operation,  21 
effects  of  time  on  mortality,  45 
general  incidence  of,  20 
nature  of  projectiles  causing,  14,  16 
present  arrangements  in  French  and 

Belgian  Armies,  49 
relative  frequency  of,  14 
table  showing  injuries  in  moribund 

cases,  24 

where  to  operate,  45 — 49 
above  transpyloric  plane,  25 
antero-posterior  hypochondriac,  20 
below  intertubercular  plane,  28 
between      transpyloric      and      inter- 
tubercular planes,  27 
epigastric,  26 

in  moribund  cases,  table  of,  24 
oblique  epigastric  and  hypochondriac, 

26 
of  hollow  alimentary  organs,  treatment 

of,  65 

of  oesophagus,  <)."> 
of  stomach,  frequency  of,  65 

situation  of,  66 
of  viscera,  comparative  frequency  of, 

41 

on  back  to  be  first  treated,  60 
penetrating,   possibility  of  escape   of 

viscera,  29 
position  of,  and  direction  of  missile, 

influence  on  prognosis,  21 
posterior  and  lateral  wounds  of  hypo- 
chondriac regions,  27 
production  after  penetration,   mecha- 
nism of,  40 

vertical  epigastric  and  hypochondriac, 
26 

X-RAYS,  value  of,  01 


THE    WHITEHRIAKS    I'RESS,    LTD.,    LONDON    AND    TOJJBB1DGE. 


ANGELES,  CAUFORN,A9oi 

which  it  was  borrow^ 


3   1970  00315   1542 


000  450  703  4 


I 

CO 


Wallace,  Sir  Cuthbert  S 

War  surgery  of  the  abdomen. 


WO  800 

Wl87v 

1918 


CJ 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


Univer 

Sou 

Lit 


